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ORAL  ANAESTHESIA 

LOCAL  ANAESTHESIA  IN 
THE  ORAL  CAVITY 


TECHNIQUE    AND    PRACTICAL    APPLICATION   IN 
THE  DIFFERENT   BRANCHES  OF  DENTISTRY 


By 
KURT   HERMANN   THOMA,  D.M.D. 

Assistant  in  Anaesthesia,  Harvard    Dental    School,    Harvard    University 

Assistant  in   Dental    Anatomy,    Harvard   Medical  School,    Harvard   University 

Fellow    of    the    Harriet  N.  Lowell  Society  for  Dental   Research   of   Harvard 
University 

Member  of  National,  State  and  Local  Dental  Societies 


BOSTON.   MASSACHUSETTS 

RITTER  &  FLEBBE 
120  BOYLSTON  STREET 


^>}0 


(The    right   of   reproduction    of   the    original  illustrations   is 
strictly   reserved.) 

Copyrighted  at  the  Registry  of  Copyrights,  Washington,  D.C., 
19 1 4.     All  rights  reserved. 


CONTENTS 


Page 

I.     INTRODUCTION       7 


II.    ANATOMY  OF  THE  ORAL  CAVITY   .  9 

1.  OSTEOLOGY 9 

Maxilla 9 

Mandibula ^'^ 

2.  NEUROLOGY 25 

The  Ophthalmic  nerve 25 

The  Maxillary  nerve 25 

The  Spheno-palatine  ganglion          .        .       .        .  Zo 

The  Mandibular  nerve 31 

III.  TOPOGRAPHY 35 

The  Mucous  membrane  of  the  mouth  35 

The  Pterygo-mandibular   space     ....  38 

IV.  PHARMACOLOGY 39 

1.  NOVOCAIN 39 

2.  SUPRARENIN   SYNTHETICUM     ...  41 


CONTENTS 


3.  NOVOCAIN  SUPRARENIN  COMBINED  ?4 

Seidel's  16  Theses 44 

Seidel's  method 47 

Ampules      .  .      .     .      .     .     .     .     .47 

Solutions 47 

Tablets,  Author's  method 48 

4.  PHYSIOLOGICAL  SALT  SOLUTION      .  50 

5.  DISTILLED  WATER 50 

V.     INSTRUMENTARIUM    .....  54 

L    INSTRUMENTS 54 

2.    TABLETS 54 

VL     PREPARING   OF  THE   SOLUTION      .  58 

Requirements  of  a  solution  prepared  from 

tablets , 58 

VII.     LOCAL  ANAESTHESIA 60 

A.  SURFACE  ANAESTHESIA 62 

Nasal  Anaesthesia 63 

B.  INFILTRATION  ANAESTHESIA    ...  63 

The  infiltration  method  in  the  maxilla      .      .  63 

Preparing  of  the  patient 64 

Preparing  of  place   for  insertion   of 

the  needle 65 

1.  Injection  on  the  labial  and  buccal  sides  66 

2.  Injection  on  the  palatal  side    ....  68 

The  infiltration  method  in  the  mandibula  .  69 

1.  Injection  on  the  labial  side  of  lower 

incisors 70 

2.  Injection  on  the  lingual  side  of  lower 

incisors 70 

Horizontal  injection 70 


CONTENTS 


Page 

C.  CONDUCTIVE   ANAESTHESIA    ...  71 

The  Conductive  method  in  the  Mandible  73 

1.  Pterygomandibular  injection  74 

2.  Mental  injection 81 

3.  Buccinator  injection 84 

The  Conductive  method  in  the  maxilla  85 

1.  Zygomatic  injection 85 

2.  Infra-orbital  injection 86 

3.  Incisive  injection 89 

4.  Posterior-palatine  injection     ...  90 

5.  Spheno-maxillary  injection     ...  90 

D.  GANGLION   ANAESTHESIA    ....  91 

Injection  into  the  Gasserian  ganglion    .  91 


Vni.     FAILURES    AND     ILL-EFFECTS    IN 

LOCAL  ANAESTHESIA 93 

True  failures  and  Ill-effects 93 

a.  No  anaesthesia  is  obtained      ...     93 

b.  Undesirable   symptoms   during  the 

anaesthesia 94 

c.  After-eff'ects 96 

Oedema 96 

After-pain 97 

Prolonged  anaesthesia    ....  97 

Psychological  Effects      ....  98 

Ill-Effects  due  to  other  sources  99 

VIII.  PRACTICAL  APPLICATIONS  OF 
LOCAL  ANAESTHESIA  IN  DIF- 
FERENT BRANCHES  OF  DEN- 
TISTRY     101 

Table      I  :  Infiltration  anaesthesia  for  the 

teeth  only 102 

Table     II :  Infiltration  anaesthesia  for  the 

teeth  and  soft  tissues 103 

Table  III  :  Conductive     anaesthesia    for 

the  teeth  only 104 

Table  IV :  Conductive     anaesthesia    for 

the  teeth  and  soft  tissues  .  .105 


CONTENTS 


Page 

1.  OPERATIVE  DENTISTRY 106 

Cavity  preparations 10b 

Removal  of  normal  pulps  .      .....   107 

Removal  of  calcified  pulps HI 

Removal  of  pulps  with  pulp  stones  .      .      .111 
Removal  of  hypertrophied  pulps     .  .111 

Removal  of  inflamed  pulps 112 

Removal  of  inflamed  pulps  complicated 

with  periodontitis 112 

Acute  alviolar  abscess  at  the  Apex .     .     .112 

Chronic  Alviolar  abscess 113 

Pericemental  abscess 114 

Diagnosis 114 

2.  GROWN   AND  BRIDGE  WORK     ...   116 

Fitting  of  bands  and  cementing  bridges     .    116 
Grinding  and  Devitalizing 118 

3.  EXODONTIA 120 

4.  ORAL  SURGERY 121 

Operation  for  granulum,  root  and  apex 

amputations 122 

Impacted  teeth 130 

Fractures  of  the  jaws 131 

Cysts,  Tumors,  Necrosis,  Odontoma   .      .131 
Cleft  palate,  Hare  lip.  Amputation  of  the 
alviolar    process,    and    Resection   of 
jaws 133 


I.    INTRODUCTION 

IN  these  days  of  nervousness,  hysteria  and  competition,  the 
dentist  stands  before  tlie  question :  How  can  I  accomplish 
my  work  Avith  the  least  discomfort  to  the  patient,  in  the 
shortest  time  and  with  the  most  j)erfect  result?  Local  anaesthe- 
sia fulfills  these  three  requirements  in  the  most  ideal  manner. 
If  there  is  no  interfering  pain,  there  is  no  reason  why  we  should 
not  accomplish  much  better  work  in  nnich  less  time. 

Does  general  Anaesthesia  or  Analgesia  fulfill  these  require- 
ments? Certainly  not.  How  can  Ave  perform  delicate  dental 
operations,  if  we  have  to  watch  a  more  or  less  complicated 
machine,  as  Avell  as  the  action  of  the  narcotic  on  the  patient, 
and  how  unpractical  is  general  anaesthesia  for  exodontia  and 
minor  oral  surgery  in  the  mouth.  Mouth  prop,  inability  of  the 
jiatient  to  cooperate,  obscured  field  of  operation  by  saliva  and 
blood,  which  is  swallowed  and  inhaled,  endless  sponging  pro- 
longing the  operation,  are  only  some  of  the  disadvantages. 
This  created  the  desire  for  something  better. 

liut  not  only  in  dentistry,  also  in  surg(n'y  arose  the  demand 
for  something  safer  with  less  strain,  discomfort  and  danger  to 
the  patient.  Professor  Bier  of  Berlin  developed  the  infiltra- 
tiou  anaesthesia  with  cocaine.  Cocaine  anaesthesia  was  then 
introduced  successfully  into  the  different  branches  of  Medicine. 
In  dentistry  cocaine  was  injected  with  much  force  through  a 
very  ehort  needle,  directly  into  the  gum,  producing  a  velum 
of  white  apj)earance.  This  decreased  the  pain  considerably  in 
extraction.  A  u'w  way  of  using  cocjiiuc  in  dentistry  was 
introduced  by  Professor  Briggs  of  Boston  in  1890.  His  method 
is  called  [iresvSiire  anaesthesia.  A  pellet  of  cocaine  is  placed 
iif)on  tlie  exfxisiire  of  a  pulp  and  pressed  in  with  a  small  piece 


INTRODUCTION 


of  iinvulcanized  rubber,  causing  anaesthesia  of  the  pulp  for 
purpose  of  devitalization.  Professor  Braun  of  Zwickau  worked 
out  a  new  technique  and  system  of  local  anaesthesia,  which 
aroused  promptly  great  interest  in  our  profession.  On  account 
of  the  idiosyncratic  behavior  of  cocaine,  men  of  science  looked 
for  a  substitute.  Among  several  hundred  preparations,  "Novo- 
cain," discovered  by  Professor  Einhorn  of  Munich  was  found 
the  best.  The  dentists  of  Germany  were  quick  in  realizing  the 
advantages  of  the  new  technique  combined  with  the  new  drug. 
In  utilizing  for  our  profession,  Braun' s  original  ideas,  different 
methods  of  injection,  and  various  ways  of  preparing  of  the 
anaesthetic  solution  developed.  The  most  distinguished 
German  authors  are  Braun,  Haertel,  Fischer,  Seidel,  Buente, 
Moral,  Steinkamm  and  Hauptmeyer. 

Local  Anaesthesia  is  based  upon  thorough  knoAvledge  of  the 
oral  Anatomy,  scrupulous  asepsis,  fresh  drugs,  and  exact  tech- 
nique. 


II.    ANATOMY   OF  THE 
ORAL  CAVITY 

Only  those  structures  of  the  Anatomy  of  the  oral  cavity 
which  are  intimately  connected  with  Local  Anaesthesia  shall 
be  considered  in  this  book, 

I.    OSTEOLOGY 

The  formation  and  make-up  of  the  maxilla  and  mandibula, 
the  two  bones  containing  the  teeth,  is  of  somewhat  different 
character.  The  mandible  resembles  more  a  flat  bone;  it  even 
could  be  compared  Avith  a  rib,  while  the  maxilla  is  of  irregular 
type,  containing  the  principal  air  sinuses  of  the  face. 

The  maxillary  bone  encloses  a  large  cavity,  the  max- 
Maxilla     illary  sinus   (O.  T.  Antrum  of  Highmore).       Its 

walls,  therefore,  are  very  thin.  Of  the  four  sur- 
faces the  anterior  and  infra-temporal  are  of  special  interest  to 
us,  also  the  alviolar,  zygomatic  and  palatal  processes,  and  the 
infra-orbital,  posterior  alviolar  and  posterior  palatine  fora- 
mina. 

a.  The  Anterior  surface  (O.  T.  external  or  facial  surface) 
presents  an  eminence  over  the  root  of  the  cuspid,  called  the 
canine  eminence,  which  separates  the  incisive  from  the  canine 
fossa.  Above  this  lies  the  infra-orbital  foramen  under  which 
the  levator  anguli  oris  takes  its  origin.  The  incisive  fossa 
gives  origin  to  the  compressor  nasi,  above  and  below  and  more 
to  the  median  line,  to  the  depressor  septi  (O.  T.  depressor  alae 
nasi). 

b.  The  Infra-temporal  surface  (O.  T.  posterior  or  zygo- 
matic siirfiic(')   is  convex,  directed  bjickwards  Jincl  inward.     It 


Fig.  1.     Outer  surface  of  Maxilla  and  Mandibula  showing  attachments  of  muscles. 

A  :  m.    Temporalis  ;   B  :  m.    Masseter  ;    C  :  m.    Levator    anguli    oris  ;    D.  m.  Compressor 

nasi ;  E  :  m.  Depressor  septi ;  F  @  H  :  m.  Buccinator  ;  G  :  m.  Masseter  ;    K  :  m.  Depressor 

anguli    oris;    L :  m.    Depressor  labii   inferior;    M  :  m.   Depressor   menti ;    N  :  m.   Platysma 

myoides. 


ANATOMY  OF  THE  ORAL  CAVITY  11 

forms  part  of  the  zygomatic  fossa.  It  is  separated  from  the 
anterior  surface  by  the  zygomatic  process.  It  contains  the 
posterior  alviolar  foramina.  At  its  posterior  and  inferior  part 
is  a  rounded  eminence,  the  tuber  maxillare.  This  gives  attach- 
ments to  a  few  fibers  of  the  external  pterygoid  muscle. 

c.  The  Zygomatic  process  (O.  T.  Malar  process)  extends 
from  over  the  second  molar  to  articulate  with  the  malar  bone. 
Its  posterior  surface  is  convex  and  forms  part  of  the  zygomatic 
fossa. 

d.  The  Alviolar  process  is  made  up  of  an  inner  and  outer 
plate,  which  are  connected  with  numerous  ,septa  of  cancellated 
bone.  The  outer  plate  is  continuous  with  the  anterior  and 
infra-temporal  surfaces  and  is  marked  by  vertical  ridges  corre- 
sponding with  the  roots  of  the  teeth.  It  is  quite  thin  and  frail 
over  the  incisors,  cuspids  and  bicuspids,  containing  numerous 
small  foramina,  giving  the  bone  a  porous  appearance.  A  very 
thin  plate  of  bone  separates  the  maxillary  sinus  from  the 
canine  fossa.  Further  back  in  the  region  of  the  molars,  the 
process  becomes  thicker  and  a  cortical  airia,  with  very  few  fora- 
mina is  usually  found  at  the  root  of  the  zygomatic  process. 
The  posterior  extremity  forms  the  tuberosity  which  again  is 
very  porous  around  the  alviolus  for  the  wisdom  tooth.  TJte 
inner  plate  of  the  alviolar  process  is  much  heavier  and  stronger, 
small  pores  are  evenly  distributed  throughout  its  extent.  At 
its  upper  extremity  it  joins  the  palatal  process.  The  alviolar 
process  gives  origin  to  the  buccinator  muscle  at  the  posterior 
part  of  its  outer  plate,  near  its  upper  margin,  which  reaches  as 
far  forward  as  the  first  molar  or  second  bicuspid. 

e.  The  palatal  process  projects  horizontally  inward  to 
form  the  roof  of  the  mouth  together  with  a  portion  of  the  pala- 
tal bone.  In  the  median  line  of  the  anterior  part,  we  find  the 
incisive  foramen,  at  the  posterior  and  external  sides  are  the  two 
palatine  foramina. 

f.  The  Infra-orbital  foramen  is  situated  immediately  be- 
low the  center  of  the  infra-orbital  ridge  and   near  the  ni)i)er 


Fig.  2.     Skull  showing  small  foramina  in  the  incisor  region  of  the  maxilla  and 
mandibula.     Note  also   Infra-orbital  and  mental   foramina. 


Fkj.  3.     Skull    showing    f(jraniiiia   in   tlic   cuspid,   bicuspid   and   molar   regions   of 
the  maxilla  and  absence  in  the  mandibula. 


14  ORAL    ANAESTHESIA 

margin  of  the  canine  fossa,  above  the  root  of  the  first  bicuspid. 
It  is  oval  in  shape  and  transmits  the  infra-orbital  nerve  and 
blood  vessels. 

g.  The  posterior  alviolar  foramina  are  situated  at  the  pos- 
terior part  of  the  infra-temporal  surface,  and  are  usually  two 
in  number.  They  lead  into  canals  of  the  same  name  which 
transmit  the  posterior  alviolar  vessels  and  nerves. 

h.  The  Incisive  foramen  lies  immediately  behind  the  in- 
cisor teeth  in  the  median  line.  It  is  formed  by  four  canals, 
two  lateral  ones  for  the  descending  palatine  arteries,  and  two, 
one  in  front  and  one  behind,  in  the  median  line,  for  the  naso- 
palatine nerves. 

i.  The  Palatine  Foramina.  There  is  a  larger  and  a 
smaller  foramen,  the  first  transmits  the  anterior  palatine  nerves 
and  vessels,  the  other  lies  almost  immediately  behind  it  and 
transmits  the  middle  j)alatine  nerve  and  vessels,  which  supply 
the  soft  palate.  The  larger  palatine  foramen  is  situated  at  the 
level  of  the  third  molar  or  in  children  at  the  level  of  the  last 
molar  present.  It  is  the  outlet  of  the  i^alatine  canal  made  up 
of  the  maxillary  and  palatine  bones. 

j.  The  Maxillary  sinus  (O.  T.  Antrum  of  Highmore),  va- 
ries considerably  in  shape,  size  and  cai^acity.  Its  posterior  wall 
is  crossed  by  the  posterior  alviolar  nerves,  which  they  enter  by 
special  foramina.  On  its  external  wall  we  find  a  canal  for  the 
middle  alviolar  nerve,  which  runs  downward  and  forward  to  the 
bicuspid  region,  and  on  its  anterior  wall  we  find  the  anterior 
alviolar  canal,  in  which  the  anterior  alviolar  nerves  descend. 
It  runs  inward  toAvards  the  nose  and  downward  towards  the 
incisors.  The  superior  surface  is  formed  by  the  floor  of  the 
orbit,  which  contains  the  infra-orbital  canal. 

This  bone  is  much  denser  than  the  maxilla,  and 
Mandibula      also  has  much  thicker  and  very  cortical  layers. 
It  is  divided  into  a  body  and  two  rami.       The 
body  of  the  mandible  consists  of  an  external  and  internal  sur- 
face, and  of  tlie  alviolar  process. 


1 

^■■1 

'»-■'.                                            T^^^^^^ 

^^^^^1 

g 

^IH 

/  ^^^^^^^F* 

1 

1^1 

ii.f^^ 

Fig.  4.     Palate  of  a  child  6-7  years,  note   location   of  incisive  and  palatine 

foramina. 


Fig.  5.     Palate  of  a  child   11-12  years,  nntc  location  of  incisive  and  palatine 

tdraniitia. 


Fig.  6.     Palate  of  an  adult,  note  location  of  incisive  and  palatal  foramina. 


Fig.  7.     Palate  of  senile  skull,  note  location  of  incisive  and  palatine  foramina. 


Fig.  8.     Skull   with   dissected   anterior   superior  alviolar  canal. 


Fig.  9.     Radiograph  showing  a  frontal  aspect  of  the  maxillary  sinus.     Anterior  middle 
and    infra-orbital    canals,    infra-orbital    foramen    and    superior     alviolar  plexus. 


ANATOMY  OF  THE  ORAL  CAVITY 


19 


THE  BODY  OF  THE  MANDIBLE 
a.  The  External  surface  of  the  body  of  the  mandible  pre- 
sents the  two  mental  foramina,  one  on  either  side,  the  external 
obliqne  line  which  is  eontinnons  from  the  ramns,  and  the  mental 
fossa.  The  mental  fossa  lies  directly  beneath  the  incisor  teeth, 
and  is  very  porons.  Showing  many  small  foramina  similar  to 
the  ones  aronnd  the  roots  of  the  maxillary  teeth.     These  are 


B. 


A 


Fig.  10.  Cross  section  through  maxilla  and  mandibula  showing  difference  in 
makeup  of  the  bone.  A.  Frontal  section  through  maxillary  alviolar  process. 
R.  Frontal   section  through   niandihular   alviolar   process.     I'oth   in   the   l)icuspi(l 

region. 

made  use  of  for  \\n-,  in  (ill  ration  method  of  local  anaesthesia. 
The  H'st  of  tli<*  surface  is  iiliiiost  one;  cortical  mass. 

b.  The  Internal  surface  of  tlie  liody  likewise  is  iiia<le  up  of 
a  very  heavy  hiyci-  of  lioiic,  willi  tlic  c.xccplion  of  tlie  region  of 
the  genial  I  iiImm-cIcs,  wIici-c  wc  HikI  ;i  cjiiiinihilcd  area. 


20 


ORAL   ANAESTHESIA 


c.  The  alviolar  process  of  the  mandibula  is  much 
stronger  than  the  alviolar  process  of  the  maxilla.  In  the 
molar  region  it  is  even  reenforced  by  the  external  and  internal 
oblique  lines.  The  alviolar  ridge  shows  perforations,  especially 
well  marked  in  the  bicuspid  and  incisor  regions,  but  the  part 
near  the  roots  and  over  the  apices  of  the  teeth  is  non-cahiculated 
with  the  exceptions  mentioned,  on  both  sides  of  the  incisor 
teeth. 

THE  RAMUS  OF  THE  MANDIBLE 

It  presents  three  surfaces,  the  external,  anterior  and 
internal  surfaces. 

a.  The  external  surface  of  the  ramus  gives  attachment 
to  the  Masseter  muscle. 

b.  The  anterior  surface  forms  a  triangle  called  the  post- 
molar  triangle.  Its  external  boundary  is  the  external  oblique 
line,  which  starts  from  the  anterior  margin  of  the  coronoid 
process,  and  passes  downward  and  outward  to  the  external 
surface  of  the  body  of  the  mandible,  where  it  is  continued  as  a 
well-marked  ridge.     This  is  a  pronounced  landmark,  which  can 


Fig.    11.     Three   mandibles    showing    different    construction    of   the  post-molar  triangle, 
a  Internal  oblique  line,    b  External  oblique  line,   c  Post-molar  triangle. 


ANATOMY  OF  THE  ORAL  CAVITY 


21 


be  easily  palpitated  in  the  mouth.  The  internal  boundary  of 
the  post-molar  triangle  is  the  internal  oblique  line,  which  is 
varying,  sometimes  well  marked,  other  times  rounded,  and  hard 
to  find.  The  base  is  formed  by  the  wisdom  tooth.  The  triangle 
is  concave  and  can  be  easily  felt  with  the  tips  of  the  fingers.  It 
lies  behind  and  externally  to  the  last  molar. 

c.  The  internal  surface  of  the  ramus  presents  about  its 
center  the  mandibular  foramen.  This  is  the  opening  into  the 
mandibular  canal.  The  margin  of  the  foramen  presents  at  its 
anterior  side  a  prominent  lingula,  the  mandibular  tongue.  To 
this  is  attached  the  spheno-mandibular  ligament.  The  man- 
dibular tongue  is  varying  in  size  from  a  tongue  like  to  a  thick- 
ened process.  From  this  a  decided  groove  starts,  running 
obliquely  downward,  for  the  mylohyoid  nerve  and  artery.  At 
the  angle  of  the  ramus,  we  find  rough  oblique  ridges,  to  give 
insertion  to  the  internal  pterygoid  muscle.  This  muscle  covers 
the  mandibular  foramen  completely,  with  the  exception  of  a 
circular  space.  This  space  is  called  ptenjgo-mandihular  space 
from  its  position  between  the  pterygoid  muscle  and  the  man- 
dible. Its  outline  is  the  sulcus  mandihularis,  a  groove  found 
around  the  foramen. 


I'ic.   12.     Sulcus  mandihularis  enclosed  by  the   dotted   line. 


22 


OILiL    ANAESTHESIA 


d.  The  Mandibular  canal  (O.  T.  Inferior  dental  canal) 
runs  obliquel}^  downward  and  forward  in  the  substance  of  the 
ramus,  and  then  horizontally  forward  in  the  body  of  the  man- 
dible. It  lies  close  to  tlie  inner  compact  layer,  immediately 
under  the  alviolae  into  which  small  branches  extend,  given  off 
from  the  main  canal,  for  the  nerves  and  vessels  which  supply 
the  teeth.  In  the  median  line  anastomosis  with  the  opposite 
side  takes  place. 


Fig.  13.     Specimen  showing  dissected  mandibular  canal. 


e.  The  Mandibular  Foramen  (O.  T.  Inferior  dental  fora- 
men )  is  situated  about  the  middle  of  the  internal  surface  of  the 
ramus,  halfway  between  the  anterior  and  posterior  border  (in 
a  horizontal  line  varying  slightly  between  the  alviolar  border 
and  the  coronal  surface  of  the  molars).  Viewing  the  mandible 
from  in  front,  it  seems  covered  by  the  internal  oblique  line  on 
account  of  the  angle  of  the  ramus  to  the  median  line,  which 
varies  in  different  individuals.  The  inferior  alviolar  nerves 
and  vessels  are  protected  by  the  lingula,  when  entering  the  fora- 
men, and  therefore  an  injection  for  this  nerve  has  to  be  made 
above  the  lingula,  into  the  pterygo-mandibular  space. 


JNJTOMY  OF  THE  ORAL  CAflTY 


23 


f.      The   Mental   foramen  lies   billow   ;iiul    hctwciMi   the   tirst 
and  second  bicuspids,  usually  nearer  and  s(»nietinies  entirely 


™  _ 

^^^^i 

K^^'  ¥      '^^^'^H 

^H^      ^'  ■    i^l^^B 

It^S 

^s^^^^^ 

k»1»»»l'''>' 

,.._-,  -_ 

Fkj.   14.     Variations   of   the  intc-rnal   surface  of   llie   ramus   nian<lii)ularis.     Note 

tlie    lingula,    sulcus    mandil)ularis.    and    mandibular    foramina    in    the    different 

specimen.     The  first  from  a  younji  the  la'-t  from  a  senile  individual. 


24 


ORAL   ANAESTHESIA 


below  the  second  bicuspid.  It  is  the  communication  with  the 
mandibular  canal,  and  gives  exit  to  the  mental  nerve  and  ves- 
sels. 


Fig.   is.     Location  of  mental   foramen  in  a  child. 


Fig.  16.     Location  of  mental  foramen  in  adult. 


Fig.  17.     Location  of  mental  foramen  in  senile  skull. 


ANATOMY  OF  THE  ORAL  CAVITY  25 


2.     NEUROLOGY 

The  trigeminal  or  Vtli  cranial  nerve  has  a  larger,  or  sensory, 
and  a  smaller,  or  motor  root.  The  large  root  forms  the  semi- 
Innar  ganglion.     The  Vth  nerve  is  divided  into 

1.  Ophthalmic  nerve. 

2.  Maxillary  nerve  (O.  T.  Superior  maxillary). 

3.  Mandibular  nerve  (O.  T.  Inferior  maxillary). 

The  Ophthalmic  nerve  supplies  no  tissue 

The  Ophthalmic    in  the  oral  cavity.     It  supplies  the  eye-ball. 

Nerve  the  lacrimal  gland,  the  lining  of  the  eye, 

and  nasal  fossa,  the  skin  of  the  eyebrow, 
forehead  and  nose.  It  is  only  so  far  of  interest  to  us  as  in 
some  cases  of  neuralgia  the  pain  is  referred  to  this  branch. 

The  maxillary  nerve  comes  from  the  foramen 
The  Maxillary   rotudum  entering  the  spheno-maxillary  fossa. 
Nerve  Here  it  gives  off — 

The  zygomatic  branch,  supplying  the  skin  of 
the  side  of  the  forehead  and  of  the  cheek. 

The  spheno-palatine  nerves,  which  form  the  sensor}",  or 
short,  roots  of  the  spheno-palatine  ganglion. 

The  posterior  superior  alviolar  rami  are  given  off  just  be- 
fore the  nerve  enters  the  infra-orbital  canal.  They  are  two  or 
three  in  number,  but  often  have  a  common  trunk,  and  then 
divide  and  pass  downward  on  the  tuberosity  of  the  maxilla. 
They  give  off  twigs  to  the  buccal  part  of  the  gum  and  mucous 
membrane  of  the  cheek;  these  are  called  the  superior  gingival 
brandies.  The  posterior  alviolar  branches  enter  from  the  in- 
fra-temporal surface  of  the  maxilla  into  the  posterior  alviolar 
canals.  They  supply  the  mucous  membrane  of  the  maxillary 
sinus,  and  then  take  part  in  the  formation  of  the  superior 
dental  plexus,  suj)plying  the  molar  teeth,  tlie  alviolo-dontal 
membrane  and  tlie  gum. 


Fig.  18.     Nervus  trigeminus;    (Vth   cranial  nerve)    12.   N.  opticus;   14.  ganglion 
semilunare ;    (Gasseri)    15.   N.   maxillaris;   26.    N.   mandibularis. 


ANATOMY  OF  THE  ORAL  CAVITY 


27 


\v. 


c 


^- 


1    %- 


Co. 

1 


.y^'^^r^^y 


Fig.  19.  Schematic  drawing  of  the  Nervus  maxillaris.  V.  Ganglion  semilunarc ; 
I.  N.  opthalmicus;  II.  N.  maxillaris;  III.  N.  mandibularis ;  1.  Nn.  spheno-pala- 
tine;  2.  Rami  alviolares  superiores  posteriores ;  3.  Ramus  alviolaris  superior 
medius;  4.  N.  infra-orbitalis ;  5.  Rami  palpebrales ;  6.  Rami  nasales ;  7.  Rami 
labiales;  8.  Rami  alviolares  superiores  anteriores;  9.  Plexus  dentalis  superior; 
10.  Ramus  dentalis  superior;  11.  Ramus  gingivalis  superior;  a.  F.  rotundum ;  b. 
F.  ovale;  c.  Canalis  infra-orbitalis;  d.  F.  infra-orbitalis;  e.   Foramina  alviolaria 

posteriores. 

The  middle  superior  alviolar  ramus  is  given  off  from  the 
maxillary  nerve  just  before  it  enters  tlie  infra-orbital  canal  or 
from  the  infra-orbital  at  its  beginning.  It  runs  downward  and 
forward  in  a  special  canal  on  the  outer  wall  of  the  maxillary 
sinus,  which  it  often  enters  on  the  infra-temporal  surface  of  the 
maxilhirv  bone.  It  joins  into  the  superior  dental  plexus,  to 
supply  the  bicuspid  teeth. 

The  Infra-orbital  nerve.  This  is  the  name  of  the  second 
division,  after  it  cTilcrs  the  infra-orbital  caual.     It  follows  the 


28  ORviL   ANAESTHESIA 

course  of  the  artery,  and  soon  gives  off  the  middle  superior 
alviolar  ramus  (if  the  latter  is  not  given  off  in  the  spheno-max- 
illary  fossa) .  Before  its  exit  through  the  infra-orbital  foramen 
it  gives  off  the  anterior  superior  alviolar  ramus.  After  coming 
to  the  outside  of  the  face,  it  divides  into  the  rami  infra-orbi- 
tales. 

Rami  infra-orbitals.  These  are  three  sets  and  anastomose 
with  the  facial  nerves.  They  are  called,  palpebral,  nasal  and 
labial,  and  form  the  facial  plexus. 

The  Anterior  superior  alviolar  ramus,  is  the  largest.  As 
a  common  trunk,  it  runs  through  a  canal  in  the  anterior  wall 
of  the  antrum ;  then  divides  into  a  series  of  branches,  supplying 
the  incisor  teeth  and  cuspids,  anastomosing  with  the  middle 
superior  alviolar  branches  by  a  plexus.  These  also  supply  the 
fore  part  of  the  mucous  membrane  of  the  inferior  meatus  of 
the  nose.  It  is  a  common  observation  that  by  anaesthetizing 
the  mucous  membrane  of  the  nose,  the  patient  complains  of 
numbness  of  the  front  teeth.  This  nerve  can  be  reached  by 
injecting  into  the  infra-orbital  foramen  from  the  vestibule  of 
the  mouth. 

Superior  dental  plexus.  As  described,  it  is  formed  by  the 
three  superior  alviolar  branches.  From  it  come  the  branches 
that  supply  the  teeth  and  the  alviolar  process. 

Superior  dental  rami.  They  are  the  small  nerve  fibers 
that  enter  the  root  of  the  teeth  by  the  apical  foramen  to  take 
part  in  the  formation  of  the  pulps,  supplying  also  the  alviolo- 
dontal  membrane. 

Superior  gingival  rami.  They  are  the  branches  that  pass 
into  the  alviolar  process  and  supply  the  gum. 

THE  SPHENO-PALATINE  GANGLION 

This  is  deeply  placed  in  the  spheno-maxillary  fossa.  It  is 
heart  shaped  and  lies  just  below  the  maxillary  nerve  from 
which  it  receives  its  two  sensory  roots.     The  motor  root  comes 


l-iG.    20. 


palatine    part. 


(  V'lli    ci'anial    nerve ).         Ir 
In    tlic   Mandilnila :    lingual 


tile    nia.xilla;    naso- 
iierve. 


30 


ORAL   ANAESTHESIA 


Fig.  21.  Schematic  drawing  of  ganglion  spheno-palatinum.  V.  ganglion  semilu- 
nare ;  I.  N.  ophthalmicus;  II.  N.  maxillaris ;  III.  N.  mandibularis ;  1.  Nn. 
spheno-palatini ;  2.  N.  vidii;  3.  N.  petrosus  snperficialis  major  (from  N.  facialis)  ; 
4.  N.  petrosus  profundus  (from  carotid  plexus);  5.  N.  pharyngis;  6.  N.  naso- 
palatinus ;  7.  8.  Rami  nasales ;  9.  N.  palatinus  anterior ;  10.  N.  palatinus  medius ; 
11.  N.  palatinus  posterior;  a.  F.  rotundum;  b.  F.  ovale;  c.  F.  incisivum;  d.  F. 
palatinum  majus;   e.    F.  palatinum   minor. 

from  the  facial  nerve,  and  is  called  the  large  superficial  petro- 
sal ;  the  sympathetic  root  comes  from  the  carotid  plexus,  and  is 
called  the  deep  petrosal.  They  join  and  form  the  Vidian  nerve. 
From  the  branches  of  the  spheno-palatine  ganglion  there  are 
of  interest  to  us. 

The  Anterior  palatine  nerve,  which  passes  through  the 
palatine  canal,  and  emerges  through  the  palatine  foramen.  It 
is  accompanied  by  the  artery,  and  supplies  the  hard  palate,  as 
far  forward  as  the  cuspid  teeth. 


ANATOMY  OF  THE  ORAL  CAVITY  31 


The  Middle  palatine  nerve.  This  emerges  through  thvi 
accessory  palatine  foramen,  supj^lying  the  soft  pahite,  nviila 
ancb  tonsils. 

The  posterior  palatine  nerve,  supplying  the  musi^les  of  tin- 
soft  palate. 

The  naso-palatine  nerve.  This  takes  tlie  course  from  the 
spheno-palatine  foramen  across  the  inside  of  the  roof  of  the 
nose  until  it  reaches  the  septum.  From  here  it  passes  down- 
ward and  forward  between  the  periosteum  and  the  mucous 
membrane  to  reacli  the  incisive  foramen.  It  is  distributed  over 
the  anterior  part  of  the  hard  palate,  anastomosing  witli  the 
anterior  i)alatine  nerve. 

The  mandibular  nerve  is  made  up  of  a  large, 
The  or  sensory,  and  a  small,  or  motor,  part.     It 

Mandibular         takes  its  exit  from  the  skull  through  the  fora- 
Nerve  men   ovale.     Immediately   afterwards   it   di- 

vides into  an  anterior  and  a  posterior  part. 
The  anterior  branch  is  nearly  all  motor  nerves,  and  sup- 
plies the  muscles  of  mastication.     Its  branches  are 

Internal  pterygoid  nerve, 
^lasseter  nerve. 
Deep  temporal  nerve. 
Buccinator  nerve. 
External  pterygoid  nerve. 
Auriculo-temporal  nerve. 

TIk;  posterior  part  consists  of 
Lingual  nerve. 
Inferioi-  alviolar  nerve. 

Of  these  we  wjiiit   1(»  consider: 

Buccinator  nerve.  1'liis  nerve  ]>asses  ^(»l•^\  ;ii'<l  from  be- 
tween the  two  hejuls  of  jlie  external  ))terygoi(l  nniscle,  then 
thi-ongh  the  temi)oral  muscle  to  the  surface  of  the  bnccinalof 
mUHcie.      It  <livides  into  two  bi-nnches — 

Suijerior  ramus,  to  supply  integinent  nnd  the  supei-i(»i-  p;ii*r 
of  the  bucciruitoi-  inuscle. 


Fig.  22.     Nervus  trigeminus:   (Vth  cranial  nerve).     In  the  Maxilla  showing  the  anterior 
part  of  the  N.  maxillaris.     In  the  mandibula  showing  the  N.  mandibularis. 


ANATOMY  OF  THE  ORAL  CAVITY 


ZZ 


Inferior  ramus,  wliicli  passes  forward  to  the  angle  of  the 
mouth.  It  supplies  the  integment  of  the  muscle,  and  the 
mucous  membrane  of  the  cheek,  also  the  buccal  side  of  the  gum 
in  the  lower  jaw  between  the  first  bicuspid  and  second  molar. 


c. 

<.»C 


I'lfj.  1.1.     Scliematic  drawing  of  ncrviis  mandihiilaris.     V.   ganglion  semilunarc; 

1.  N.  ophthalmicus;  II.  N.  maxillaris;  III.  N.  mandihiilaris;  1.  N.  huccinatorius ; 

2.  X.  massetericus ;  3.  Nn.  temporalis  profundus;  4.  N.  ptcrygoidcus  cxternus ; 
5  X.  pterygoideus  intcrnus;  6.  X.  auricolo  lcm]joraIis ;  7.  X.  alviolaris  inferior; 
8.  X.  lingualis;  9.  X.  mentalis;  10.  X.  niylohyoideus ;  11.  Ramus  dentalis  in- 
ferior; 12.  Ramus  gingivalis  inferior;  a.  F.   mandihularis ;   h.    F.   mentalis;    c.    F, 

rotundum  ;  d.  F.  ovale. 


34  ORAL   ANAESTHESIA 

The  Lingual  nerve.  This  first  runs  with  the  inferior  alvio- 
lar  nerve,  situated  on  its  inner  side,  but  soon  passes  further 
forward  and  descends  between  the  ramus  of  the  mandible  and 
internal  pterygoid  muscle,  passing  down  at  its  anterior  margin, 
and  finally  crossing  over  to  the  side  of  the  tongue.  It  sujjplies 
the  anterior  two-thirds  of  the  tongue.  On  its  way  it  gives  off 
side  branches,  which  run  along  the  inner  surface  of  the  man- 
dible asi  far  as  the  anterior  part,  where  it  is  minutely  broken 
up  in  the  periosteum.  This  branch  supplies  the  whole  lingual 
surface  of  the  gum. 

The  Inferior  alviolar  nerve  (O.  T.  inferior-dental).  This 
is  the  largest  of  the  branches  of  the  mandibular  nerve.  It 
passes  downward  with  the  inferior  alviolar  artery,  at  first 
beneath  the  external  pterygoid  muscle,  then  between  the  inner 
side  of  the  ramus  and  the  internal  pterygoid  muscle.  It  enters 
the  pterygo-maudibular  space,  in  which  it  enters  the  man- 
dibular foramen,  accompanied  by  the  artery.  Before  doing  so, 
however,  it  gives  off  the  mylohyoid  nerve.  The  inferior  alvio- 
lar nerve  then  follows  the  mandibular  canal,  forming  the  infe- 
rior dental  plexus  and  giving  off  the  mental  branch. 

Inferior  dental  plexus.  This  is  formed  by  the  different 
branches  to  the  teeth  and  alviolar  process,  and  in  front  by  anas- 
tomosis of  the  nerve  coming  from  the  opposite  side. 

Inferior  dental  rami.  They  enter  the  roots  of  the  teeth  to 
take  part  in  the  formation  of  the  pulp  and  also  supply  the 
alviolo-dontal  membrane. 

Inferior  gingival  rami.  They  supply  the  alviolar  process 
and  gums. 

The  Mental  nerve.  It  is  a  branch  of  the  inferior  alviolar 
nerve.  It  emerges  through  the  mental  foramen,  and  supplies 
the  skin  of  the  chin  and  the  mucous  membrane  of  the  lower  lip 
and  the  anterior  labial  part  of  the  gum,  communicating  freely 
with  the  facial  nerve. 


III.    TOPOGRAPHY 

It  is  of  importance  to  know  the  makeup  of  the 
The  Mucous  soft  tissue  of  the  mouth,  and  the  relations  of 
Membrane  the  structures  we  have  to  deal  with.  The  mu- 
of  the  Mouth  cons  membrane  lines  the  entire  oral  cavity.  It 
consists  of  epithelium  and  tunica  propria.  Un- 
derneath this  and  forming  the  deeper  part  is  the  submucosa. 

The  submucosa  consists  of  thick  connective  tissue  bundles 
containing  numerous  elastic  fibers,  which  extend  into  the  peri- 
osteum, but  become  finer  towards  the  tunica  propria.  In  the 
gums,  the  submucosa  is  very  dense,  binding  the  mucous  mem- 
brane down  closely  to  the  periosteum.  As  it  passes  into  the 
mucous  membrane  of  the  cheek  and  lip  it  becomes  less  dense, 
and  under  the  reflection  of  the  mucous  membrane  the  submu- 
cosa is  a  thick  layer  of  loose  connective  tissue.  The  same  is  true 
on  tlie  palatal  side.  The  angle  formed  by  the  alviolar  and 
palatal  process  is  filled  in  with  a  large  amount  of  connective 
tissue,  containing  fat  cells  and  the  palatal  mucous  glands. 
Over  tlie  central  portion  of  the  hard  palate,  the  subnuicosa  is 
again  very  thin  and  extremely  fibrous. 

The  tiiiiicM  ]»r()]»i-i;i  is  made  ii]»  of  a  mass  of  dense  connective 
tissue  bundles,  and  papilhie  are  extending  into  the  epithelium. 

Tlie  epitlieliiim  is  the  thick  covering  of  the  mucous  mem- 
brane. 

'I'lic  blood  snpi)ly  is  very  free,  larger  branches  are  found  in 
tlie  submucosa  giving  off  capillaries,  which  extend  into  the  pa- 
pillae of  the  tunica  propria,  where  they  freely  ramify  and  anas- 
tomose    These  give  llie  mucous  membrane  its  reddish  color. 

Xeives  aie  iiiiiiieioiis.  Primitive  nerve  fibers  extend  from 
tlie  suliiiiiicosa    iiilo   llie   |»a|)illae  of  Hie  hiiiica    pro|)ria.     The 


Fig.  24.     Section   through   the   upper  jaw   in   the   incisor    region.       A.   Enamel; 

B.  Dentin ;  C.  Interglobular  spaces ;  D.  Epithelium ;  E.  Tunica  propria ;  F.  Sub- 

mucosa;  G.  Periosteum;  H.  Outer  Plate  of  alviolar  process;  I.  Inner  Plate  of 

alviolar  process;  K.  Cement;  L.  Dental  nerves  and  vessels. 


TOPOGRAPHY 


37 


nerve  supply  seems  to  be  more  abundant  in  the  anterior  part  of 
the  month,  while  the  molar  region  of  the  gnm,  and  the  mem- 
brane over  the  ramus  is  hardly  sensitive. 

Injections  should  be  made  into  the  loose  parts  of  the  sub- 
mucosa,  where  the  solution  is  taken  up  easily  with  little  force. 


Fig.  25.  Horizontal  section  through  human  head  in  tlic  phme  in  which  mandib- 
ular conductive  anaesthesia  is  best  accompHslicd.  a.  Glandula  parotis;  b.  Ramus 
mandibulac;  c.  Fascia  parotidcomasscterica ;  d.  Nervus  alvcolaris  inf.;  e.  A.  and 
V.  alvcolaris  inf.;  f.  Sj)atium  pterygomandibulare ;  g.  M.  masselcr;  h.  M.  ptery- 
goid int.;  i.  Nervus  lingualis;  k.  M.  buccinator;  1.  Glandulae  i)alatinae;  m.  Art. 
maxillaris  externa;  n.  Glandulae  buccalis;  o.  Gingiva;  p.  Labium  inferius; 
q.  Lingua;  r.  Glandulae  buccalis;  s.  M.  masseter;  t.  M.  Diagastricus ;  u.  Art. 
carotis  externa;  v.  Vena  jugularis  interna;  w.  N.  vagus,  glossopharyngeus  and 
hypoglossus;  x.  Art.  carotis  interna;  y.  Ganglion  cervicale  superior;  z.  M.  longus 

capitis. 

A,    M.    rectus   capitis   anterior;    B.    Fpistropheus ;    C.    M.    constrictor   pharyngis 

.superior;  D.  Fascia  praevertebralis ;  ]•'.  M.  stylopharyngeus ;  F.  M.  styloglossus; 

G.   Tonsilla   i)alatina ;    11.   M.    stylohyoidcus. 


38  ORAL    ANAESTHESIA 

Injecting  into  the  dense  submucosa  of  the  gum,  as  in  the  old 

method,  requires  much  pressure  and  is  incorrect. 

It  also  is  important  not  to  inject  into  one  of  the  vessels. 

This  can  be  avoided  by  moving  the  syringe  slightly  forth  and 

back. 

The  pterygo-mandibular  space  is  bounded  ex- 

The  Pterygo-  ternally  by  the  part  of  the  internal  surface  of 
Mandibular  the  mandibular  ramus,  enclosed  in  the  sulcus 
Space  mandibularis,  internally  by  the  internal  pter- 

ygoid muscle.  It  is  a  bag-like  space  filled  with 
connective  tissue.  In  it  the  alviolar  nerve  and  artery  enter 
the  mandibular  foramen.  The  artery  lies  anteriorly  to  the 
nerve  and  is  protected  by  the  lingula,  the  nerve  is  more  to  the 
median  line  and  posteriorly  to  the  artery.  The  inferior  alviolar 
vein  forms  a  plexus  around  the  artery.  The  lingual  nerve  is 
seen  in  a  section  cut  through  the  pterygo-mandibular  space  at 
the  anterior  margin  of  the  internal  pterygoid  muscle. 


IV.    PHARMACOLOGY 

I.     NOVOCAIN 

There  is  no  reason  today  why  cocaine,  for  which  so  many 
patients  have  an  idiosyncrasy,  should  still  be  used  in  any  branch 
of  medicine.  The  toxity  of  cocaine  was  not  so  clearly  under- 
stood in  the  beginning,  and  occurring  deaths  were  first  thought 
to  be  due  to  overdoses.  But  experience  showed  that  in  some 
cases,  very  large  doses  could  be  administered  without  any  bad 
effects,  while  other  cases  were  reported  where  death  occurred 
from  as  small  a  dose  as  0.01  gram.  Besides  the  danger  of  idio- 
syncrasy, there  are  a  number  of  diseases  where  cocaine  is  con- 
tra-indicated on  account  of  its  toxic  action  on  the  general  sys- 
tem, especially  on  the  nerves,  kidneys,  and  heart.  These  are 
anaemia,  chlorosis,  neurasthenia,  nephritis,  heart  diseases, 
arterio  sclerosis  and  general  weakness,  often  illness.  It  is  also 
a  great  disadvantage  that  cocaine  decomposes  partly  when 
boiled,  losing  much  of  its  anaesthesia  producing  power. 

Therefore  a  large  number  of  men  of  science  searched  for 
years  for  a  substitute.  Professor  Braun,  the  "father  of  Local 
Anaesthesia,"  formulated  the  following  requests,  qualities, 
which  the  new  preparation  should  possess. 

1.  The  substitute  shall  not  be  inferior  to  cocaine  in  its 
anaesthesia  producing  i)ower. 

2.  It  shall  be  relatively  non-toxic. 

3.  It  shall  have  no  irritating  action,  even  on  the  most  deli- 
cate tissues. 

4.  It  nmst  be  easy  to  combine  it  with  suprarenin  and  com- 
bined, it  should  not  lose  of  its  anaesthesia  producing  power, 
neither  should  it  affect  the  action  of  the  suprarenin. 

5.  It  must  be  boibibh*. 


40  ORAL    ANAESTHESIA 

Among  tbe  many  preparations,  which  have  all  been  thor- 
oughly tested  out  by  men  like  Professor  Braun  and  Professor 
Bier,  Novocain  was  found  to  be  by  far  the  best. 

It  was  prepared  by  Professor  Einhorn  in  Munich,  and  is  the 
"hydrochlorid  of  the  p-Aminobenzoyldiethylaminoethanol" 
with  the  formula : 

N  H. 

C  O.     C,  H4.     N  (C2H5),;    H  CI. 


Q  H,  <;;^ 


-D      J      ^-         It  IS  produced    through  the  action  of  '^diethyl- 
Froduction  ^  *  \^ 

amin'-  upon  "p-Aminobenzoeacidchlorethylester. 

It  occurs  in  small,  colorless  and  tasteless  crystals, 
Chemical  soluble  in  water  (1 :1),  and  less  soluble  in  alcohol 
Properties     ( 1 :30 ) .     It  is  also  soluble  in  glycerine  at  20  Cen- 

tigrades  (1:5).  Melting  point  156  Centigrades.  It 
can  be  heated  without  decomjDOsition  to  120  Centigrades. 

It  shows  the  general  alcaloid  reactions,  tincture  of 
Reactions   iodine  j)roduces  a  brown,  picric  acid,  a  yellow  pre- 
cipitate.    Alkalies    produce    a    white    precipitate, 
which  is  soluble  in  alcohol  and  ether. 

If  one  mixes  a  solution  of  0.1  gram  Novocain  in  5  c.c.  of 
water,  and  three  drops  of  dilute  sulphuric  acid  with  five  drops 
of  potassiumpermanganate,  we  find  that  the  violet  color  disap- 
pears at  once.     This  distinguishes  Novocain  from  Cocaine. 

Novocain  possesses  the  same  action  upon 
Physiological  peripheral  sensory  nerves  as  cocaine.  The 
Properties  0.25   per   cent   solution  is  sufficient  to  com- 

pletely anaesthetize  even  the  thick  nerve  trunks 
in  about  ten  minues. 

(Pharmacological  institute  of  the  University  in 
Clinical  Breslau.)  Locally  applied  there  is  no  irritation. 
Tests  even  if  Novocain  is  brought  upon  the  most  sensitive 

tissue  in  strongly  concentrated  solutions,  as  upon 
the  cornea.     General  effects  upon  the  system  after  its  absorp- 


PHARMACOLOGY  41 


tion  are  scarcely  perceptible,  neither  the  circulation  nor  the 
respiration  snffers,  the  blood  pressnre  is  not  increased.  From 
experiments  it  was  found  that  Novocain  is  seven  times  less 
toxic  than  cocaine. 

The  best  solution  for  our  purpose  is  the  two  per  cent 
Dosage  solution,  for  the  infiltration  as  well  as  for  the  con- 
ductive method.  A  change  of  strength  is  not  required 
for  special  cases,  and  I  have  used  it  most  successfully  in  cases 
where  cocaine  and  ether  anaesthesia  was  contra-indicated  on 
account  of  cardiac,  pulmonary  or  other  diseases.  The  maximal 
dose  is  0.5  gram  (Fischer)  for  subcutaneous  injections,  but  as 
much  as  2  gram  has  been  used  subcutaneously,  without  causing 
any  damage.  But  in  our  specialty  such  a  quantity  is  never 
called  for,  and  the  maximal  dose  which  allows  24  c.c,  or  12 
syringes  full  of  a  two  per  cent  solution  is  hardly  ever  reached. 

2.     SUPRARENIN   SYNTHETICUM 

Suprarenin  has  a  great  anaemia  producing  power,  and  is  a 
strong  astringent.  It  is  added  to  the  anaesthetic  solution  for 
one  of  two,  or  two  purposes.  First  to  contract  the  capillaries 
and  tissue  locally,  to  prevent  absorption  and  infiltration  into 
the  soft  tissue,  therefore  increasing  duration  and  strength  of 
the  anaestliesia.  Secondly,  it  is  added  to  decrease  bleeding  in 
certain  operations.  It  is  much  superior  to  adrenoline,  or  any 
of  the  organic  substances  gained  from  the  suprarenal  glands, 
as  it  is  more  staple,  keeps  better  and  is  less  toxic.  It  is  the 
"Ilydrochlorid  of  0-Dioxyphenylethonolmethylamin,"  and  has 
the  chemical  formula : 


< 


C  H  (O  Hj  C  Ho.  N  H.  C  H3 

(\\],C     OH 

OH  H  CI. 


r>      J      >•        <J)loracetobreiizkateciiin   is    irauslormed   by    me- 
rroduction    ,  .        .  ,,        ,      .  ,         , 

tnylamin      into      Methylaminacetobrenzkatechm. 

\\y  reducing  this  keton  we  receive  the  secondary  alco- 
hol called  syiitliefic  suj)rarenin. 


42  ORAL    ANAESTHESIA 

Synthetic  Suprarenin  is  a  grayish  white  powder. 
Chemical  It  does  not  dissolve  easily  in  cold  nor  in  hot  water, 
Properties    and  is  insoluble  in  alcohol  and  ether.     Melting 

point  207-208  Centigrades. 
Titrated  with  diluted  acids  it  is  very  easily  soluble  and 
gives  a  watery  clear  solution.     It  is  in  the  market  diluted 
1 :1000. 

Synthetic  suprarenin  is  very  sensitive.  Free  al- 
Reactions  kali,  air  and  especially  heat  cause  its  decomposi- 
tion. It  has  to  be  kept  in  bottles  made  of  special 
alkali  free  glass,  and  should  not  be  exposed  to  air  unnecessarily. 
It  has  the  advantage  over  the  organic  preparation  that  it  can 
be  boiled  to  some  extent.  Slightly  discolored  solutions  have 
toxic  or  irrigating  effects. 

It  is  the  strongest  Haemastatic  and  astringent 
Physiological  known.  It  causes  anaemia  and  contraction  of 
Properties  capillaries  and  tissues  locally,  while  when  in- 

troduced into  the  circulation  it  increases  the 
blood  pressure.  This  comes  partly  from  increased  heart  action, 
and  partly  from  contraction  of  the  arteriols  in  the  whole  body. 

Clinical  experiences  in  different  institutions  and 
Clinical  hospitals  of  Europe  proved  Suprarenin   Syn- 

Experiences    thetic  to  be  the  best  substitute  for  the  organic 

preparation. 

Different  than  with  Novocain,  I  found  it  of  great 
Dosage    importance  to  vary  the  amount  of  Suprarenin  for 

individual  cases.  I  have  been  using  the  E  tablets, 
which  contain  0.000,05  grams  suprarenin  to  1  c.c,  if  a  two  per 
cent  solution  is  prepared,  and  I  only  came  to  the  conclusion 
that  so  high  a  percentage  of  Suprarenin  is  not  necessary,  while 
treating  a  patient  with  grave  cardiac  and  pulmonary  disorders. 
He  was  referred  to  me  for  treatment  under  local  anaesthesia, 
by  another  dentist.     Considering  the  seriousness  of  the  situa- 


PHARMACOLOGY  43 


tiou,  I  prepared  a  special  solution  containing  two  per  cent 
Novocain  and  0.000,01  gram  Snprarenin  to  1  c.c.  I  used  the 
infiltration  and  conductive  methods  in  the  upper  and  the 
conductive  method  in  the  lower  jaw,  with  perfect  result,  and  to 
mj  surprise  I  found  that'  the  time  of  anaesthesia  was  not 
decreased.  I  then  tried  the  new  solution  on  a  patient,  Avhich 
had  slight  toxic  effects,  immediately  after  the  injection  of  a 
solution  containing  0.000,05  gram  Suprarenin,  with  encourag- 
ing result.  In  conductive  anaesthesia  of  the  mandible,  we 
sometimes  find  that  the  lip  feels  perfectly  numb,  that  the  den- 
tine is  sufficiently  desensitized,  but  the  pulp  only  partly  anaes- 
thetized. Fischer  agreed  with  me  that  this  is  probably  due  to 
the  fact  that  the  tooth  in  question  is  supplied  by  the  central 
nerve  fibers  of  the  nerve  trunk,  which  are  not  reached  by  the 
anaesthetic.  This  teaches  two  things,  first',  that  we  should 
allow  time  enough  for  the  drug  to  act,  and  second,  that  the 
suprarenin  should  be  used  in  small  percentage  for  conduc- 
tive anaesthesia,  on  account  of  its  astringent  action,  probably 
preventing  in  high  concentration  the  infiltration  of  the  nerve 
trunk  to  its  center. 

Conclusively  I  lay  the  cause  of  slight  toxic  effects,  post- 
operatic  pain  in  extraction,  post-operatic  infection,  and  oedema 
as  after-effect,  as  well  as  incomplete  conductive  anaesthesia  to 
a  too  large  percentge  of  suprarenin. 

For  general  use  I  found  a  solution  containing  0.000,015- 
0.000,02  gram  of  synthetic  suprarenin,  to  1  c.c.  or  a  0.0015- 
{).Wyi'/c  solution  of  suprarenin  the  best. 

For  cases  where  a  deep  anaemia  is  desired,  a  higher  per- 
centage of  0.000,05  gram  per  1  c.c.  or  0.005%  is  recommended. 

For  patients  with  heart  diseases,  arterio-sclerosis,  nephritis 
and  liysteria  a  lower  percentage  of  suprarenin  is  advisable. 
Use  not  more  than  0.000.01  gram  to  1  c.c,  or  0.001%. 


44  ORAL    ANAESTHESIA 


3.     NOVOCAIN  SUPRARENIN   COMBINED 

At  a  congress  of  German  dentists  held  in  Mnenster,  Ger- 
many, at  which  the  German  authorities  on  local  anaesthesia 
met,  Seidel  proposed  sixteen  theses  formnlating  use  and  dosage 
of  the  Novocain-Suprarenin  solutions.  The  problem  was  thor- 
oughly discussed  by  Fischer,  Apffelstaedt,  Moral,  Steinkamm, 
Hauptmeyer,  Buente,  Friedmann,  Heinemann,  Endres,  Rilke 
and  Heinze  during  the  two  days'  meeting  and  finally  accepted 
by  unanimous  vote  as  follows  : 

SEIDEL'S  16  THESES 

I.  The  fresher  a  Novocain-Suprarenin  solution 
is,  the  less  is  its  toxity,  and  the  greater  is  its  anaes- 
thesia producing  power.  Therefore  when  exam- 
ining preparations  scientifically,  one  should  only 
use  freshly  self-prepared  solutions.  One  can  only 
get  a  clear  picture  of  the  power  of  the  Novocain- 
Suprarenin  solutions,  if  one  is  sure  that  the  solu- 
tion used  contains  Novocain  and  Suprarenin  pure, 
and  not  products  of  deterioration, 

II.  Fresh  Novocain  and  Suprarenin  either  sep- 
arate or  mixed  (solutions)  should  be  clear  as 
water. 

III.  For  the  practice  a  Novocain  solution 
should  only  be  considered  "fresh"  and  fully  active, 
if  clear  and  colorless. 

IV.  The  same  is  true  for  solutions  of  supra- 
renin. Solutions  of  suprarenin  are  less  stable  the 
more  diluted  they  are. 

V.  Mixed  Novocain-Suprarenin  solution  is  only 
to  be  considered  "fresh"  directly  after  the  mixing 
of  the  dissolved  parts. 


PHARMACOLOGY  45 


Already  iu  ten  minutes  a  Xovocain-Suprareniu 
solution  will  show  discoloration  (from  high  tem- 
perature, action  of  light  or  air),  diminishing  its 
power  and  increasing  its  toxity. 

VI.  A  sterile  Novocain-Suprarenin  solution 
cannot  be  made  lasting  through  addition  of  anti- 
septics, because  the  yellow  discoloration  of  the 
Novocain,  and  the  red  discoloration  of  the  supra- 
renin  are  due  to  chemical  processes  (oxydation) 
and  not  bacterial  influences. 

Therefore  a  Novocain-Suprarenin  solution  should 
be  sterile,  but  an  antiseptic  character  is  not  re- 
quired. 

VII.  Antiseptic  additions  [e.  g.,  Thymol,  and 
others,  as  in  patented  preparations  (author)]  are 
not  only  unnecessary  but  directly  injurious.  At 
the  present  time  there  is  no  antiseptic  known  which 
is  entirely  non-irritant  in  a  concentration  powerful 
enough  to  have  sufficient  antiseptic  properties. 

VIII.  Individualizing  the  concentration  of 
Novocain  is  not  required  for  the  small  doses  used 
for  dental  ])urposes  and,  contrar}^  to  cocaine,  it 
makes  no  difference  whether  a  certain  dose  is  in- 
jected in  weak  or  strong  concentration,  as  long  as 
the  total  doses  of  0.2  grams  is  not  transgressed. 

IX.  In  dentistry  where  the  part  to  be  anaes- 
thetized (bone  and  tooth)  cannot  be  infiltrated 
directly,  but  where  in  contrary  a  diffusion  is  re- 
quired, a  solution  of  a  comparatively  high  percent- 
age can  l)e  used  only. 

X.  The  best  solution  for  dental  purposes  is  the 
two  per  cent  solution. 


46  ORAL   ANAESTHESIA 


XI.  The  suprarenin  concentration  has  to  be 
changed  in  many  cases.     This  is  required  because : 

1.  The  toxity  of  the  suprarenin  is  dependent 
from  the  concentration  in  which  a  certain  dosis  is 
given.  Tliis  is  important  in  arterio-sclerosis  and 
when  unintentionally  injecting  into  a  vessel. 

2.  In  many  cases  a  strong  anaemia  of  the  field 
of  operation  is  required,  in  others  bleeding  is  de- 
sirable. 

XII.  In  normal  cases  the  best  results  are  ob- 
tained if  the  two  per  cent  Novocain  solution  con- 
tains 0.000,02  grams  Suprarenin  per  1  c.c. 

XIII.  In  arterio-sclerosis  or  cardiac  disorders  a 
decrease  of  the  suprarenin  dosis  to  0.000,01  gram 
is  recommended.  If  strong  anaemia  is  desired  an 
increase  to  0.000,05  grams  is  required. 

XIV.  The  question  what  percentage  of  salt 
should  be  added  to  the  solution  to  make  it  isotonic 
is  not  yet  scientifically  solved. 

The  material  presented  by  Buente  and  Moral,  as 
well  as  by  Fischer,  is  not  sufficient. 

XV.  In  practice  we  find  no  difference  if  0.6  or 
0.9  gram  salt  is  added  to  a  two  per  cent  solution 
of  Novocain.  The  amount  which  also  fulfills  the 
theoretical  requirements  is  not  yet  known. 

XVI.  The  above  requirements  cannot  be  ful- 
filled in  practice  by  the  use  of  ampules  or  tablets, 
ready  for  a  solution  of  one  certain  percentage. 
The  operator  should  prepare  and  mix  the  solution 
himself,  as  with  the  method  described  by  Seidel  or 
similar  ones. 


PHARMACOLOGY  47 


SEIDEL'S   METHOD 

SeideFs  Method*  of  preparing  the  solution  is  a  very  scien- 
tific one.  He  originated  an  instrumentarium  consisting  of  au 
apparatus  to  produce  distilled  water  and  a  sterilizer  to  sterilize 
tlie  bottles,  and  other  instruments  used;  also  to  sterilize  the 
two  per  cent  Novocain  solution,  which  is  kept  in  a  special 
bottle.  The  suprarenin  solution  1 :1000  can  be  bought  in  Ger- 
many in  small  original  bottles  of  5  c.c,  from  this  the  normal 
pipette  constructed  as  a  bottle  is  filled.  Before  injecting  he 
prepares  the  solution  by  measuring  the  amount  of  Novocain 
solution,  and  adding  as  many  normal  drops  of  Suprarenin  solu- 
tion as  required  for  the  individual  case. 

This  method  no  doubt  is  ideal,  but  the  preparing  and  ster- 
ilizing of  the  solution  takes  time,  and  the  responsibility  is  too 
great  to  leave  in  charge  of  any  office  help.  Also  the  sensitive- 
ness of  the  Suprarenin  solution  is  to  be  considered.  In  this 
country,  we  have  not  the  facility  to  get  this  ingredient  directly 
and  in  shortest  time.  If  injections  are  not  frequently  used 
there  is  also  a  great  deal  of  waste,  as  the  Suprarenin  solution 
does  not  keep  long  after  the  bottle  has  been  opened.  The 
danger  to  use  Suprarenin,  the  toxity  of  whicli  has  been  in- 
creased through  influences  of  air,  heat,  light  or  age,  is  too  great 
to  take  chances. 

AMPULES 

Ampules  containing  mixtures  of  Novocain  and  Suprarenin 
are  in  the  market,  also  patented  preparations  containing  other 
ingredients.  SeideFs  Theses  Yl  and  VII  discard  the  latter, 
the  former  are  also  quite  far  from  tlie  ideal,  Tlieses  V  calling 
a  mixed  solution  of  Novocain  fresh  only  directly  after  the 
mixing.  Often  the  solutions  gained  from  ampules  are  actually 
discolored  jind,  wliat  is  worse,  it  is  hard  to  control  their  age. 

SOLUTIONS 

Solutions  pnt  up  in  bottles  are  still  more  undesirable  than 
the  ampules.     After  the  bottle  is  once  opened  the  rest  deterior- 

*   DeutHche   Monatschrift   fuer   Zahnheilkunde   Heft.    8-1913. 


48  ORAL   ANAESTHESIA 

ates  quickly  from  bacterial  invasion,  and  chemical  processes 
night,  air,  heat.)     See  Theses  VI  and  VII,  also  II,  V  and  IX. 

TABLETS:  AUTHOR'S  METHOD 

I  have  used  solutions  prepared  from  tablets  in  private  prac- 
tice and  school  clinics  entirely,  with  the  exception  only  of  short 
periods  when  I  tried  out  other  methods.  The  tablets  of  Farb- 
werke  Hoechst  I  found  very  satisfactory,  they  are  carefully  and 
scientifically  made  and  very  reliable.  Professor  Braun  ex- 
amines them  every  year  and  finds  that  they  are  always  sterile. 
This  of  course  is  of  first  importance.  I  used  and  recommended 
the  E  tablet,  but,  as  explained  in  a  previous  chapter,  I  found 
that  they  contain  too  much  Suprarenin,  and  that  it  is  necessary 
to  vary  the  amount  of  Suprarenin.  I  therefore  prepared  solu- 
tions from  the  D  and  F  tablets.  This  of  course  is  somewhat 
complicated  for  general  use.  To  simplify  the  technique  of  pre- 
paring the  solution,  Farbwerke  Hoechst  was  kind  enough  to 
produce  a  new  tablet.  I  therefore  use  now,  and  recommend 
for  general  use.  Tablet  T. 

Tablets  T       For  all  anaesthesia  in  the  oral  cavity,  either  for 
for  purely  dontal  or  for  surgical  operations,  the  solu- 

General  Use  tion  is  prepared  from  the  T  tablets.    This  tablet 
dissolved  in  1  c.c.  of  salt  solution  gives  a  solution 
containing  two  j)er  cent  Novocain  and  0.000,02  gram  of  Supra- 
renin to  1  c.c. 

Tablets  E  If  deep  anaemia  is  desired,  as  in  cases  of  dif&- 
for  Deep  cult  surgical  operations  (root  amputations,  im- 
Anaemia  pacted  third  molars,  etc.),  the  E  tablets  can  be 
used  to  prepare  the  solution.  This  tablet  dis- 
solved in  1  c.c.  of  physiological  salt  solution  gives  a  solution 
containing  two  per  cent  of  Novocain  and  0.000,05  gram  of  Su- 
prarenin to  1  c.c. 


PHARMACOLOGY  49 


Tablet  F  For  abnormal  cases,  arterio-sclerosis,  nephritis, 

combined  grave  cardiac  disorders,  hysteria,  use  two  F 
with  tablets  plus  one  E  tablet  dissolved  in  6  c.c.  of 

Tablet  E  salt  solution.     This  gives  a  two  per  cent  solu- 

tion of  Novocain  containing  only  0.000,009 
gram  of  Suprarenin  to  1  c.c. 

These  solutions  I  find  very  satisfactory,  and  they  also  come 
very  close  to  the  fulfillment  of  the  Sixteen  Theses  of  Seidel. 
The  solution  prepared  by  dissolving  the  tablets  in  the  salt  solu- 
tion, just  before  the  injection  is  made  fulfills  the  requirements 
of  Theses  I  to  X.  Thesis  V  discards  solutions  of  Suprarenin 
and  Novocain,  which  are  not  mixed  by  the  operator  imme- 
diately before  the  injection.  In  the  tablets  the  two  ingredients 
are  mixed  in  a  dry  state,  in  which  they  are  better  preserved,  and 
as  long  as  no  moisture  penetrates  into  the  tube,  which  is  pre- 
vented by  the  rubber  stopper,  they  do  not  deteriorate.  When 
the  tablets  are  dissolved  we  get  a  water  clear  solution  which, 
in  accord  with  Thesis  II,  is  to  be  considered  "fresh."  Theses 
XI,  XII,  and  XIII  call  for  different  Suprarenin  concentra- 
tions. There  are  three  concentrations  required,  the  normal 
strength  being  0.000,02  grams,  which  we  get  Avitli  the  "T" 
tal)let;  the  increased  strength  being  0.000,05  grams  which  we 
get  with  the  "E''  tablet;  and  the  decreased  strength  being 
0.000,01  gram,  which  is  only  recommended  for  very  serious  dis- 
orders. If  such  a  solution  is  recpiired  it  can  be  obtained  by  dis- 
solving two  Y  tablets  and  one  E  tablet  in  0  c.c.  of  salt  solution, 
tins  gives  a  two  per  cent  Novocain  solution  Avith  0.000,009  gram 
Suprarenin.  Theses  XIV  and  XV  have  to  do  with  the  salt 
solution,  and  Tliesis  XVI  advocates  Seidel's  method,  which 
certainly  is  ideal,  but  not  adaptable  for  us. 

I  li;iv(i  proved  to  my  satisfaction  that  llu;  "tablet  method"  is 
very  little  behind  the  method  of  "separate  solutions,''  if  the 
solution  is  pn^pared  coiiscieiit  ioiisly,  and  if  we  vary  the  strength 
of  Suprarenin. 


50  ORAL   ANAESTHESIA 


4.    PHYSIOLOGICAL  SALT   SOLUTION 

The  question  whether  a  0.6  or  0.9%  salt  solution  with  two 
per  cent  Novocain  is  isotonic,  is  theoretically  not  yet  solved,  as 
seen  from  Theses  XIV  and  XV.  In  practice,  however,  I  found 
Braun's  solution  very  satisfactory;  he  recommends  to  add  a, 
very  small  amount  of  dilute  hydrochloric  acid  to  offset  the 
derogatory  action  of  the  glass  alkali  and  to  prevent  oxidation 
of  the  Suprarenin.     His  solution  is  : 

Sodii  chloridi  puriss 2.0 

Acidi  hydrochlorid.  Diluti gtt.l 

Aquae  dest 300.0 

Fill  the  bottle  with  this  solution  and  boil  it  fifteen  minutes. 
Lately,  however,  a  new  solution,  called  Kinger  solution,  has 
been  recommended.  It  contains  the  salts  found  in  the  blood, 
and  is  claimed  to  fulfill  the  requirements  better  still.  It  con- 
tains Calcium  chloride,  which  was  found  by  Professor  Guerber, 
Director  of  the  Pharmacological  Institute,  Marburg,  to  im- 
prove the  process  of  absorption  in  the  tissue,  and  to  stimulate 
the  action  of  the  leukozytes.  I  have  been  using  the  Ringer 
solution  for  the  last  three  months ;  it  contains : 

Sodium  chloride   0.50 

Calcium  chloride 0.04 

Potassium  chloride 0.02 

Aquae  dest 100.00 

There  are  Ringer  tablets  on  the  market,  which  are  dissolved 
in  distilled  water :  ten  tablets  to  100  c.c.  aqua  dest.  The  solu- 
tion is  then  boiled  for  fifteen  minutes.  These  simplify  the  self- 
production  of  the  salt  solution. 

5.    DISTILLED   WATER 

The  greatest  difficulty  for  the  conscientious  practitioner  is 
to  get  perfectly  distilled  water.     The  druggist  does  not  keep 


I'i';.  26.      I'cincI   Ajjiiaraliis   to   ijrodiirc   dislillfd    water. 


52 


ORAL   ANAESTHESIA 


the  distilled  water  in  aseptic  condition,  and  in  a  short  time  it 
becomes  impure  by  the  growth  of  all  kinds  of  fungi  and  their 
products.  Vegetations  of  these  often  can  be  seen  with  the 
naked  eye,  swimming  around  in  the  bottle.  Although  the  fungi 
themselves  are  killed  when  dissolving  the  tablets,  there  are 
still  the  dead  cells  and  the  previously  formed  toxins  toi  be  con- 


LooIiTi o- water  imlet.  i>>-_^ ■ 


Cooli.y\^eitt'\:  outlet 


Fig.   27.     Schematic   drawing  of  distilled   water  apparatus. 


sidered.  Ehrlich  found  that  Infusions  of  Salvarsan  made  with 
commercial  distilled  water,  caused  toxic  effects  which  did  not 
occur  if  fresh,  sterile,  distilled  water  was  used. 

It  is  therefore  commendable  to  have  special  distilled  water 
prepared  by  a  reliable  druggist,  which  then  is  measured  into 
the  well-cleaned  and  dealkalied  bottle.  After  adding  the 
Einger  tablets  cook  it  for  fifteen  minutes. 


PHARMACOLOGY  53 


For  large  clinics,  it  is  advisable,  and  in  private  practice 
possible,  to  produce  sterile,  toxin-free,  distilled  water  with 
the  Femel  Apparatus.*  The  handling  is  ver^^  simple.  Bottle 
A  is  filled  with  commercial  distilled  water,  and  the  cooler  is 
mounted  with  a  rubber  stopper.  Cooling  water  is  connected  to 
the  inlet  and  a  tube  takes  care  of  the  overflow.  The  outlet  for 
the  distilled  water  is  connected  by  a  special  glass  tube  to  the 
bottle.  The  gas  is  lit  under  bottle  A  (without  letting  the  cool- 
ing water  run)  to  produce  steam,  which  sterilizes  the  whole 
outfit.  Now  the  cooling  water  is  opened  carefullj'  and  allowed 
to  run  very  slowly.  The  distilled  water  runs  into  the  bottle, 
into  which  the  Ringer  tablets  are  added. 

*   F.    and  M.    Laiiti'iischhiser,  Berlin   X.   39;    Chausseestrasse   92. 


V.    INSTRUMENTARIUM 

The  instruments  required  for  quick,  safe,  and  aseptic  work 
are: 

Two  Fischer  syringes,  one  mounted  in  a  short  hub  ^yith  a 
26  mm.,  the  other  in  a  long  hub  with  a  45  mm.  iridio-platinum 
needle.  I  prefer  iridio-platinum  needles  because  it  simplifies 
matters,  in  that  they  do  not  need  to  be  boiled  before  use,  can 
be  used  again,  and  therefore  can  always  be  mounted  on  the 
syringe  ready  for  use.  These  do  not  break.  If  steel  needles 
are  used,  Avhich  often  show  specks  of  rust  and  oxide,  one  has 
to  boil  them  and  should  only  use  them  once.  The  platinum 
needles  have  to  be  sharpened  from  time  to  time  Avith  a  round 
engine  stone. 

The  syringes  are  kept  in  a  glass  jar  with  absolute  alcohol, 
placed  on  a  stand,  together  with  two  porcelain  dissolving  cups. 

The  dissolving  cups  are  graduated,  one  up  to  three,  the 
other  up  to  10  c.c,  and  are  used  to  measure,  dissolve  and  ster- 
ilize the  anaesthetic  solution.  They  are  made  of  porcelain, 
which  can  be  cleaned  with  dilute  hydrochloric  acid. 

The  bottle  double  corked,  contains  the  Ringer  solution. 

A  glass  tray  is  used  to  keep  tablets  and  reserve  needles. 
Also  an  engine  stone  to  sharpen  the  needles. 

TABLETS 

Novocain-Suprarenin  Synthetic  Tablet  T.* 

Novocain    0.02  gram. 

Suprarenin  Synthetic  0.000,02  gram. 

Novocain-Suprarenin  Synthetic  Tablets  E.* 

Novocain    0.02  gram. 

Suprarenin  Synthetic 0.000,05  gram. 

*   Farbwerke   Hoechst   Co.,   Ill    Hudson   Street,    New   York. 


(U  C  _ 
>  'V 
O  *j    <U 

a;   C 

be  S"^ 
•^  5   C 


<u  -^ 
be  <u 
C    o 

Si 


fc-^ 


Fig.  29.  Syringes.  The  small  syringe  with  27  gauge  platinum  needle  for 
mucous  anaesthesia  previous  to  injecting  with  the  large  syringe.  The  next 
syringe  is  Fischer's  syringe  mounted  with  the  short  needle.  The  third  is  mounted 
with  the  45mm.  long  needle,  and  the  last  one  is  mounted  with  the  bayonet  piece 
and  a  60mm.  long  needle. 


31 

1 

I 

^m?!^r^^ 

^^^^ 

WL^^ 

s 

H 

^^^ 

■ 

■ 

^ 

■ 

i 

■i 

1 

^^^^^H 

Fig.  30.     Large  and  small  dissolving  cups. 


PHARMACOLOGY 


57 


Novocain  Tablets  F*   (for  special  cases  only  to  combine  with 
the  E  Tablets). 

Novocain    0.05  gram. 

Ringer  Tablets* 

Sodiniii  Chloride 0.050         gram. 

Calcium  Chloride 0.004        gram. 

Potassium  Chloride 0.002        gram. 

Dissolve  ten  tablets  in  100  c.c.  of  aqna  dest  and  sterilize. 

*   Farbwerke    Hoechst    Co.,    Ill    Hudson    Street,    New   York. 


VI.    PREPARING  OF  THE 
SOLUTION 

Kemove  the  stand  from  the  jar  and  wash  the  cup  and  syringe 
in  distilled  water,  to  remove  all  traces  of  alcohol.  Fill  cup 
with  Kinger  solution  to  the  mark  required. 

Heat  the  solution  over  the  flame  to  boiling. 

Add  tablets  as  follows : 

For  normal  cases:  One  T  tablet  to  each  c.c.  This  gives  a 
solution  with : 

Novocain    2% 

Suprarenin 0.000,02  gr.  to  1  c.c. 

For  deep  anaemia:  One  E  tablet  to  each  c.c.  This  gives  a 
solution  with : 

Novocain    2% 

Suprarenin 0.000,05  gr.  to  1  c.c. 

For  abnormal  cases:  Two  F  tablets  and  one  E  tablet  to 
6  c.c.     This  gives  a  solution  with : 

Novocain    2  % 

Suprarenin 0.000,009  gr.  to  1  c.c. 

Draw  the  cup  through  the  flame  till  the  tablets  are  dissolved. 
Sterilize  needle  on  the  syringe  in  the  flame. 
Fill  the  syringe  and  avoid  touching  the  needle. 

REQUIREMENTS  OF  A  SOLUTION  PREPARED 
FROM  TABLETS 

1.  It  should  be  immediately  used  after  it  has  been  pre- 
pared. 

2.  The  solution  should  not  come  in  contact  with  anything 
except  the  porcelain  cup  and  the  syringe. 


The  manufacturing  of  the  T  tablets  will  be  delayed  on 
account  of  the  war.     Use  instead : 

For  normal  cases:  One  F  and  one  E  tablet  to  3.5  c.c.  This 
gives  a  solution  with 

Novocain   2% 

Suprarenin 0.000,015  gram  to  1  c.c. 


PHARMACOLOGY  59 


It  should  not  be  left  longer  than  absolutely  necessary  in  the 
dissolving  cup  nor  in  the  syringe.  The  solution  is  very  sensi- 
tive, being  affected  and  clieniically  changed  by  air,  heat,  light, 
and  especially  by  alkalies. 

3.  The  tablets  should  not  be  touched  witli  hands  nor  instru- 
ments, and  the  tube  should  be  closed  immediately  after  use, 
with  the  rubber  stopper.  The  tablets  are  chemically  changed 
by  air,  light,  and  especially  by  moisture. 

4.  The  tablets  should  be  white;  sometimes  the  uppermost 
one  discolors  from  chemical  changes,  caused  by  improper  hand- 
ling of  the  tube. 

5.  The  solution  gained  from  the  tablets  sliould  be  clear  as 
water. 

If  it  shows  any  light  pink  color,  it  should  l)e  discarded. 


VII.    LOCAL  ANAESTHESIA 

Local  Anaesthesia  has  successfully  progressed  not  only  in 
minor  but  also  in  major  surgery  since  we  have  been  enabled, 
with  the  later  methods,  to  obtain  a  really  total  anaesthesia. 
For  this  progress  we  are  principally  indebted  to  Professor 
Braun. 

There  are  now  different  possibilities  to  produce  local  anaes- 
thesia, named  according  to  that  part  of  the  sensory  nerve  sup- 
ply into  which  we  decide  to  inject. 

a.  The  Surface  Anaesthesia, 

b.  The  Infiltration  Anaesthesia. 

c.  The  Conductive  Anaesthesia. 

d.  The  Ganglion  Anaesthesia. 

e.  The  Spinal  Anaesthesia. 

The  Surface  anaesthesia  is  only  used  upon  mucous  mem- 
branes which  absorb  it  rapidly. 

The  Infiltration  method   anaesthetizes  the  peripheral  nerve 

endings. 

The  Conductive  method    intercepts   a   whole   nerve   trunk 

supplying  a  certain  area. 

The  Ganglion  anaesthesia  is  obtained  by  injecting  into  a 
ganglion,  anaesthetizing  all  the  regions  supplied  by  its 
branches. 

The  Spinal  anaesthesia  consists  of  mixing  the  anaesthetic 
solution  with  the  liquor  cerebrospinalis,  and  re-injecting  of 
both  into  the  spine.  With  this  method  much  larger  areas  can 
be  anaesthetized,  but  it  is  only  practical  in  the  lumbar  X3art  of 
the  body,  and  therefore  of  no  use  in  oral  surgery. 

In  the  oral  cavity  we  have  mainly  to  deal  with  the  V  Cra- 
nial nerve,  which  offers  many  possibilities  for  local  anaesthesia. 


PHARMACOLOGY 


61 


Often  the  question  is  asked  whether  local  anaesthesia  has  any 
bad  effects  on  the  pulp  of  the  tooth,  or  the  tissue  in  general. 
Both  questions  can  be  answered  in  the  negative.  A  tooth,  if 
anaesthetized  properly  by  the  infiltration  or  one  of  the  other 


Fig.  31.     .Schematic  illustration  of  the  inctliods  of  local  anaesthesia  recommended 

for  dental  surgery.     1.  Surface  anaesthesia.    2.   Infiltration  anaesthesia. 

.3.  Conductive  anaesthesia.     4.  Ganglion  anaesthesia. 


62  ORAL   ANAESTHESIA 

methods  named  in  this  book,  is  not  in  danger.  We  only  anaes- 
thetize the  nerve  fibers,  while  the  circulation  of  the  pulp  is  not 
interfered  with  to  any  extent,  unless  an  extremely  large  amount 
of  Suprarenin  should  be  used.  Also  the  surrounding  tissues 
do  not  suffer,  unless  irritant  antiseptics  are  added  to  the  solu- 
tion, as  in  some  preparations  which  are  on  the  market.  We 
always  inject  into  connective  tissue  from  which  the  solution 
absorbs  in  one  hour  to  one  hour  and  a  half,  unless  the  amount 
of  Suprarenin  is  too  high.  It  is  different,  however,  if  we  inject 
accidentally  the  whole  amount  into  muscle  tissue.  From  this, 
absorption  takes  place  very  slowly,  it  sometimes  requires 
several  days  till  all  is  absorbed,  during  which  time  the  muscle 
is  stiff,  sometimes  somewhat  swollen,  and  causes,  if  it  is  a 
muscle  of  mastication,  false  ankylosis.  This  disappears  with- 
out treatment.  The  danger  of  injecting  into  a  nerve  or  vessel 
is  also  often  questioned.  To  inject  into  a  nerve  trunk  has  no 
consequences  other  than  a  prompt  action  of  the  anaesthetic. 
Arteries  are  thick  walled  and  elastic,  and  therefore  are  not  easy 
to  puncture,  they  rather  go  out  of  the  way ;  veins  and  capillaries 
can  be  avoided  if  we  move  the  syringe  forth  and  back  while 
injecting. 

In  modern  local  anaesthesia  it  is  a  principle  to  separate  the 
act  of  anesthetizing  from  the  operation  proper,  having  a 
waiting  time  in  between,  during  which  the  anaesthesia  deepens. 

A.    SURFACE  ANAESTHESIA 

This  method  depends  upon  the  absorbing  quality  of  the 
mucous  membrane.  It  has  generally  no  deep  action.  If  a  twenty 
per  cent  solution  of  Novocain  made  from  the  F  tablets  is  ap- 
plied to  the  gTim  it  causes  superficial  anaesthesia  sufflcient  for 
fitting  bands  in  bridge  work  or  finishing  a  filling  at  the  cervical 
margin.  It  also  can  be  used  previous  to  the  insertion  of  the 
needle.  There  is,  however,  one  method  of  surface  anaesthesia 
which  gives  good  results,  this  is  the  anaesthesia  from  the  nose. 


LOCAL  ANAESTHESIA  63 


NASAL  ANAESTHESIA 

Place  a  piece  of  cotton  saturated  with  a  twenty  per  cent  solu- 
tion of  Novocain  into  the  inferior  meatus  of  the  nasal  cavity..  In 
a  short  time  the  solution  will  penetrate  through  the  mucous 
membrane  of  the  nose  and  anaesthetize  the  incisor  teeth  of  the 
respective  side. 

B.    INFILTRATION   ANAESTHESIA 

This  method  depends  up(m  diffusion  of  the  solution  through 
the  pores  of  the  bone,  thus  reaching  the  dental  nerve,  before 
it  enters  the  tooth. 

For  dental  anaesthesia  use : 

For  single-rooted  teeth,  labial  or  buccal  injections. 
For  multi-rooted  teeth,  buccal  and  palatal  injections. 

For  surgical  anaesthesia  use : 

For  all  teeth,  labial  or  buccal  and  palatal  injections. 

The  solution  is  injected  into  the  submucosa,  from  where  it 
penetrates  into  the  bone,  depending  upon  the  action  of  the 
Suprarenin  to  prevent  quick  absorption.  Anaesthesia  can  be 
produced  in  five  minutes  and  lasts  one  hour.  It  is  at  its  best 
in  ten  minutes,  and  after  half  an  hour  it  disappears  gradually, 
the  solution  being  absorbed  slowly. 

The  maxilla  is  (as  we  have  seen  in  another 
The  Infiltration  chapter)  especially  well  adapted  for  the  in- 
Method  in  filtration   method,   on   account  of  the  thin 

the  Maxilla  construction  of  the  outer  alviolar  plate,  and 

its  porous  make-up.  This  method  can  be 
used  for  any  teeth  in  the  upper  jaw.  The  bicuspids  and  incisors 
are  the  easiest  to  anaestlietize;  next  come  the  cuspids  and  third 
mohn-s,  while  the  first  and  second  molars  sometinies  show  some 
difficulties  on  account  of  the  zygomatic  process  forming  a  cor- 
tical mass  over  these  teeth. 


64 


ORAL   ANAESTHESIA 


PREPARING  OF  THE  PATIENT 

If  local  anaesthesia  is  to  be  used  on  a  patient  the  operator 
has  never  injected  for,  or  in  an  entirely  strange  patient,  one 
should  inquire  while  leisurely  conversing  whether  the  patient 
has  any  severe  illness,  requiring  a  decrease  in  the  percentage 
of    suprarenin.       If   the   subject   of   injection   is   opened,   the 


Fig.  32.     Frontal  section  through  the  molar  region  showing  buccal  and  palatal 
injection  by   the   infiltration   method. 

A.  Position  of  needle  for  palatal  injection;  B.  Position  of  needle  for  buccal  or 
labial  injection,  a.  Sinus  frontalis;  b.  M.  orbicularis  oris;  c.  Cellula  ethmoidahs; 
d.  Bulbus  oculi ;  e.  Concha  nasalis  inf.;  f.  Meatus  nasi  inferior;  g.  Concha  nasalis 
media;  h.  Meatus  nasi  medius;  i.  Septum  nasi;  k.  Processus  zygomaticus; 
1.  Sinus  maxillaris ;  m.  Plexus  dentalis  superior ;  n.  M.  masseter ;  o.  Mi.  buccina- 
tor; p.  Dens  molaris  primus;  q.  Membrana  mucosa  buccalis;  r.  Processus 
alveolaris;  s.  Pulpa  dentis;  t.  Membrana  mucosa  palatinae;  u.  Processus  pala- 
tinus;  v.  Cavum  oris;  w.  Cavum  buccalis;  x.  Membrana  mucosa  alveolaris; 
y.  Glandulae  palatinae;  z.   (1)    Radix  palatinae;  z.    (2)   Radix  buccalis. 


LOCAL   ANAESTHESLi 


65 


patient  usually  mentions  of  his  own  accord  previous  disagree- 
able experiences,  if  be  bas  bad  any,  and  tbe  operator  can  con- 
duct bimself  accordingly.  Tbis  is  also  tbe  time  to  assure  tbe 
patient  of  tbe  safety  of  tbis  anaesthetic,  and  of  tbe  great  advan- 
tage to  botb  tbe  patient  and  tbe  operator,  sparing  tbe  first  tbe 
pain,  and  allowing  tbe  latter  to  use  bis  best  ability  to  perform 
tbe  operation. 

PREPARATION  OF   PLACE   FOR   INSERTION   OF 
THE   NEEDLE 

An  unclean  moutb  should  first  be  sprayed  out  with  an  anti- 
septic solution.  Hold  tbe  lip  away  from  tbe  gum,  and  witb  a 
sbort  cotton  roll  wipe  all  tbe  mucus  from  tbe  field  of  opera- 
tion. Tlien  witb  a  little  bit  of  cotton  dipped  in  campbo-pbe- 
ni(pie,  or  solution  of  aconite  and  iodine,  equal  parts,  sterilize 
and  anaesthetize  tbe  part  Avhere  tbe  needle  is  to  be  inserted. 
In  very  sensitive  patients  I  use  a  small  hypodermic  syringe, 
with  a  very  fine  and  sharp  platinum  needle,  and  inject  a  few 
drops  of  Novocain  solution  previous  to  tbe  regular  injection. 


I'lf,.  33.     Position   of  operator  vvlicn    injecting   for   an    upper  tooth  by  the 
inllltration    luctliod. 


66 


ORAL   ANAESTHESIA 


1.      Injection  on  the  labial  and  buccal  side  of  the  Maxilla. 

The  point  of  insertion  on  the  labial  and  buccal  side  is  half- 
way between  the  gum  margin  and  apex  of  the  root.  For  cus- 
pids it  is  advisable  to  start  higher  up,  and  for  the  molars  one 
should  start  over  the  mesial  root,  or  still  farther  forward,  push- 
ing the  needle  obliquely  backward  and  upward,  to  reach  a  point 
between  and  a  little  higher  than  the  apices  of  the  buccal  roots. 


Fig.   34.     Radiograph   showing  the  infiltration  method  for  an  upper  incisor. 


This  to  overcome  technical  difficulties.  The  upper  wisdom 
tooth  is  sometimes  hard  to  reach,  its  neck  is  usually  well  set  in 
and  at  a  higher  level  than  the  other  molars.  In  these  cases  it 
is  best  to  use  the  long  needle,  insert  it  very  high  at  the  level 
of  the  apex,  but  further  forward  over  the  twelve-year  molar, 
and  push  it  backward  and  inward  in  horizontal  direction.  The 
process  around  the  third  molar  is  very  j)orous  and  anaesthesia 


Fig.  35.     Radiograph   showing  the  infiltration  method  for   an   upper  cuspid. 


Fio.  .36.     Radioj^raph   showinf^  the  infiltration  method    for  an  upper  hicuspid. 


68 


ORAL   ANAESTHESIA 


usually  takes  easy  effect.  Generally  the  short  needle  is  used. 
Push  it,  opening  directed  toward  the  bone,  down  to  the  perios- 
teum. A  drop  or  two  is  injected.  Now  the  syringe  is  best 
held  like  a  writing  pen,  and  after  the  first  injection  has  taken 
effect,  push  it  slowly  and  carefully  upwards,  if  necessary,  in- 
jecting as  you  go  along,  till  you  are  opposite  the  apex  of  the 
root.  Here  inject  slowly  and  evenly,  moving  the  syringe 
slightly  forth  and  back,  to  avoid  injecting  into  a  small  vein. 
In  this  manner  a  depot  of  1  to  If  c.c.  is  deposited,  into  the  sub- 
mucous tissue  between  mucous  membrane  and  bone.     Tiittle 


Fig.  37.     Wrong  position 
of  needle. 


Fig.  38.     Right  position  of 

needle  opening  pointing 

towards  the  bone. 


force  is  needed  to  inject.  After  five  to  eight  minutes,  anaes- 
thesia occurs  in  the  tooth  injected  for,  sufficient  to  extirpate 
the  pulp  without  pain.      ( See  Table  I. ) 

2.      Injection  on  the  palatal  side  of  the  maxillary  teeth. 

The  palatal  gum  of  the  maxilla  is  supplied  by  the  anterior 
palatine  and  naso-palatine  nerves,  therefore  for  surgical  opera- 
tions an  additional  injection  to  produce  anaesthesia  of  the  soft 
parts  is  required.  Also  for  the  molars,  and  often  for  the  first 
bicuspid,  a  palatal  injection  is  needed  to  anaesthetize  the 
palatal  root.  For  these  injections  we  start  at  the  gingival 
margin,  push  the  needle  down  parallel  with  the  process,  and  in- 
ject 0.25  c.c.  again  into  the  part  which  takes  up  the  solution  the 
easiest,  the  submucous  tissue.  After  five  to  eight  minutes  an- 
aesthesia occurs.     (See  Table  II.) 


LOCAL   JNJESTHESL4 


69 


AVe  have  studied  the  lower  jaw  and  found 
The  Infiltration  it  porous  only  in  the  mental  fossa,  and  at 
Method  in  the  genial  tubercles,  while  in  the  region  of 

the  Mandibula     the  back  teeth  the  bone  is  very  dense.     The 
infiltration  method,  therefore,  is  not  advis- 
able for  the  lower  jaw,  except  for  the  four  incisors. 
For  dontal  anaesthesia  use  labial  injections. 
For  surgical  anaesthesia  use  labial  and  lingual  injections. 


Fig.  39.     Radioj^rapli    slunving   tlie   infiltration   nutliod    for   a   l(nver   incisor. 


70 


ORAL    ANAESTHESIA 


1.     Injection  on  the  labial  side  of  the  mandibular  incisors. 

Here  the  procedure  is  very  much  like  in  the  maxilla,  often, 
however,  it  is  easier  to  insert  the  needle  over  the  tooth  next  to 
the  one  we  wish  to  anaesthetize,  pushing  it  obliquely  toAvard 
the  apex  of  the  tooth  in  question.      (See  Table  I.) 
2.     Injection  at  the  lingual  side  of  the  mandibular  incisors. 

The  procedure  is  very  much  like  that  at  the  palatal  side  of 
the  maxilla.  The  lingual  gum  is  supplied  by  the  lingual  nerve. 
This  injection  is  only  necessary  in  case  of  extraction  of  the 
lower  incisors.      (See  Table  II.) 

To  avoid  repeated  puncture  of  the  mucous  mem- 
Horizontal  brane,  if  several  adjoining  teeth  are  to  be  anaes- 
Injection  thetized  from  the  labial  or  buccal  side  by  the  in- 
filtration method,  the  long  needle  is  inserted 
over  the  apex  of  the  root  of  the  tooth  farthest  forward 
or    nearest    the    operator.       After    having    injected    for    this 


Fig.  40.     Radiograph   showing  the  horizontal  injection  for  bicuspid  and  molar  region. 


LOCAL  ANAESTHESIA 


71 


first  tooth,  push  the  needle  along  the  bone  in  horizontal 
direction,  till  you  have  reached  the  place  opposite  the  apex  of 
the  second  tooth ;  here  again  deposit  some  of  the  solution  and 
proceed  in  same  manner  for  the  next  tooth.  This  method  can 
be  used  for  a  series  of  teeth  in  the  incisor  region,  in  the  upper 
as  well  as  in  the  lower  jaw,  and  for  anaesthetizing  adjoining 
maxillary  bicuspids  and  molars.  The  use  of  the  horizontal 
injection  is  only  advisable  in  healthy  tissue.     It  is  easy  to  see 


Fig.  41.     Radiograph  showing  the  horizontal  injection  in   a  coronal  section. 

how  we  would  spread  an  infection,  if  the  needle  was  passed 
through  an  abscess,  while  anaesthetizing  the'  first  tooth,  all  the 
area  woubl  ))e  inoculated.  For  infected  areas  we  resort  to  the 
conductive  method.  For  surgical  anaesthesia  use  tlie  conduc- 
tive iiietliod  ;it  the  palatal  side. 

G.    CONDUCTIVE   ANAESTHESIA 

In  tlie  conductive  method  the  conductivity  of  the  main  trunk 
of  the  nerve  supplying  the  teeth  and  tissues  in  the  oral  cavity 


72 


ORAL   ANAESTHESIA 


is  intercepted  or  blocked  at  a  convenient  point,  while  in  the 
infiltration  anaesthesia  the  drng  acts  on  the  peripheral  nerves. 
As  the  place  of  insertion  is  nsually  quite  removed  from  the 
field  of  operation,  we  resort  to  this  method,  if  the  infiltra- 
tion method  is  contra-indicated  on  account  of  septic  condi- 
tions.    It  is  used  if  the  infiltration  method  cannot  be  applied, 


•^ 


Tig-  2 


T^p-  5 


n 


Fig.  42.     Conductive  Anaesthesia.     1.   Zygomatic  injection;   2.   Infra-orbital  in- 
jection;  3.   Pterygo-mandibular   injection;   4.   Mental  injection. 


LOCAL   JXJESTHESLd  73 


on  aceoiuit  of  the  anatomical  stnu-tnre  of  the  jaw.  AVe  may 
resort  to  it  if  several  teeth  supplied  by  one  nerve  trunk  are 
to  be  operated  upon,  and  we  use  it  in  combination  with  the 
infiltration  method  for  large  surgical  operations,  to  combine 
extensive  anaesthesia  with  anaemia  of  the  field  of  operation. 
Halstedt  (1885)  was  the  first  to  use  conductive  anaesthesia, 
blocking  otf  the  inferior  alviolar  nerve  at  the  mandibular  fora- 
men. 

FOR  DONTAL  OPERATIONS 
Conductive  Method      For  purely  dontal  operations  we  need 
in  the  Mandible  only  anaesthesia  of  the  nerve  which 

supplies  the  teeth.  It  enters  the  man- 
dible through  the  mandibular  fora- 
men. For  anaesthesia  of  the  molars  and  bicuspids  on  one  side, 
one  injection  over  the  mandibular  foramen  into  the  pterygo- 
mandibular space  is  sufficient.  The  cuspid  and  two  incisors 
are  sometimes  also  anaesthetized,  sometimes  remain  slightly 
sensitive  on  account  of  the  anastomosis  from  the  other  side. 
Another  injection  into  the  mental  fossa,  or  over  the  mental 
foramen  of  the  opposite  side  is  needed  in  the  latter  case.  For 
anaesthesia  of  all  the  lower  teeth,  one  should  use  two  injec- 
tions, one  over  each  of  the  mandibular  foramina. 

FOR  SURGICAL  OPERATIONS 

For  surgical  operations  we  need  not  only  anaesthesia  of  the 
teeth,  but  also  of  the  soft  tissue  surrounding  them.  On  the 
inner  side  this  region  is  supplied  by  the  lingual  nerve;  on  the 
buccal  side,  by  the  inferior  alviolar  nerve;  and  by  the  buccina- 
tor nerve  in  the  region  of  the  first  and  second  molar  and  second 
])i(nspid.  Therefore  we  need  anaesthesia  of  the  lingual  and 
Imccinator  nerve  in  addition  to  the  alviolar.  The  inferior 
alviolar  and  lingual  nerves  can  be  anaesthetized  with  the  same 
injection,  and  often  also  the  buccinator  nerve  is  reached,  espe- 
cially if  a  large  amount  is  injected.  Most  frequently,  however, 
it  is  necessary  to  inject  for  the  buccinator  nerve. 


74  ORAL   ANAESTHESIA 


Fig.  43.     Diagram  showing  injection  into  the  pterygo-mandibular  space. 

a.  N.  alviolaris  inf. ;  b.  A.  alviolaris  inf. ;  c.  N.  lingualis ;  d.  Spatium  pterygo- 
mandibulare ;  e.  Linea  obi.  externa ;  f.  Linea  obi.  interna ;  g.  Trigonium  retro- 
molare;  h.  Ramus  mandibulae;  i.  M.  masseter;  f.  M.  Pterygoid  int.;  1.  Position 

of  needle. 

I.    PTERYGO-MANDIBULAR  INJECTION 

For  the  right  side,  stand  in  front  of  the  patient,  palpitate 
the  external  oblique  line  of  the  ramus,  then  the  internal  oblique 
line  with  the  thumb  of  the  left  hand,  and  finally  place  the  tip 
of  the  thumb  into  the  depression  between,  the  post-molar  tri- 
angle. The  thumb  is  left  there  to  guide  the  insertion  of  the 
needle  and  the  other  fingers  fix  the  jaw. 

For  the  left  side,  place  the  left  arm  around  the  patient's 
head  and  palpitate  the  post-molar  triangle  with  the  tip  of  the 
index  finger.  On  this  side,  the  index  finger  serves  as  guide  for 
the  insertion  of  the  needle,  while  the  other  fingers  are  used  to 
hold  the  jaw. 

Prepare  the  place  of  insertion  in  the  usual  manner.  This 
injection  is  the  least  painful,  but,  as  in  all  cases  of  conductive 
anaesthesia,  stferilization  of  the  place  where  the  needle  is  in- 
serted and  scrupulous  asepsis  is  of  utmost  importance. 

Place  the  syringe,  mounted  with  the  long  iridio  platinum 
needle    (45   m.m.)    between  cuspid  and  first  bicuspid  of  the 


J-IG.  44.     Technique  of  inserting  the  needle  for  the  Plerygo-mandil)ular  injection.     1,  2  and  3, 
on  the   right   side;   4,   5   and   6,  on   the   left   side.       1   and   4,    fecliiigof  the  internal  oblique 
line.     2  and    •>,  adjusting  jjositiftn   of  the  syringe  parallel  witli   the  ramus.      3  and  5,  reaching 

the  pterygo-niandihular  space. 


76 


ORAL   ANAESTHESIA 


opposite  side,  and  insert  the  needle  into  tlie  mncons  membrane 
1  cm,  over  the  last  molar,  and  close  to  the  finger  nail.  Inject 
a  small  quantity  to  anaesthetize  the  superficial  structtires. 

Push  the  needle  forward  till  you  feel  the  internal  oblique 
line.     If  you  do  not  find  it,  it  is  because  you  are  too  far  to  the 


Fig.  45.     Pterj-gc-mandibular   injection   on   the   right   side;   position   on   patient. 


median  line,  in  which  case  the  error  can  be  corrected  by  punct- 
uring the  mucous  membrane  at  a  place  more  to  the  outside. 

Push  the  needle  slowly  forward  and  change  the  direction  of 
the  syringe,  so  as  to  bring  it  parallel  with  the  ramus.     This 


Q-> 


h 


[X. 


(1( 


80 


ORAL    ANAESTHESIA 


clianges  the  position  of  the  baek  part  of  the  syringe,  bringing  it 
over  the  incisors,  or  further  back  over  the  bicuspids. 

Now  comes  the  distinction  for  dental  and  surgical  anaesthe- 
sia.  The  lingual  nerve  lies  anterior  and  medially  of  the  alvio- 
lar  nerve,  halfway  between  the  alviolar  nerve  and  the  mucous 
membrane.  Therefore,  \)j  depositing  one-third  of  the  solution 
when  the  needle  is  halfway  in,  we  will  anaesthetize  the  lingual 
nerve. 


Sulcus  mandibularis  with  needle,  which  is  inserted  one  centimeter  over  the  occlusal  surface. 


After  the  lingual  nerve  has  been  injected  for,  the  syringe  is 
pushed  along  the  bone  into  the  pterygo-mandibular  space.  It 
should  reach  the  space  above  the  lingula.  If  we  insert  the 
needle  too  low,  it  passes  over  the  lingula  into  the  muscle. 
The  needle  is  now  moved  slightly  forth  and  back  while  the 
injection  is  made. 

In  this  way  we  anaesthetize  the  lingual  and  ^the  inferior 
alviolar  nerve.  If  we  want  anaesthesia  of  the  teeth  only,  we 
do  not  inject  till  we  have  reached  the  pterygo-mandibular  space, 


LOCAL   ANAESTHESLi  81 

where  we  deposit  1.5  to  2  c.c.  In  this  manner,  we  avoid  an- 
aesthesia of  the  lingual  nerve. 

It  is  of  double  advantage  not  to  inject  while  inserting  the 
needle.  The  danger  of  infiltrating  muscle  bundles  is  decreased, 
and  the  whole  amount  of  the  solution  can  be  utilized  to  anaes- 
thetize the  inferior  alviolar  nerve. 

Anaesthesia  occurs  in  fifteen  to  twenty  minutes,  and  lasts  at 
least  one  hour. 

In  children  the  needle  should  be  directed  slightly  down- 
ward; in  old  patients  slightly  upward  on  account  of  the  differ- 
ent relation  of  the  mandibular  foramen.      (See  Figure  14.) 

For  longer  anaesthesia  inject  two  syringes  full,  or  4  c.c. 
at  once.      (See  Tables  III  and  IV.) 

The  first  sign  the  patient  experiences  is  numbness  of  the 
lower  lip  and,  if  the  lingual  nerve  is  anaesthetized,  also  numb- 
ness of  the  tongue.  These  are  signs  of  a  successful  injection, 
and  occur  in  a  very  short  time.  It  is  important  in  this  anaes- 
thesia, especially  for  nerve  extractions,  to  wait  till  it  has 
reached  its  deepest  stage;  this  sometimes  takes  thirty  minutes, 
working  from  the  median  line  backwards. 

Failures  in  this  injection  occur  if  the  internal  oblique  line 
is  ignored,  if  the  needle  loses  the  contact  with  the  inner  side  of 
the  ramus,  or  if  the  injection  is  too  low.  It  is  important  to 
inject  in  a  horizontal  plane  one  centimeter  over  the  last  molar 
to  reach  the  pterygo-mandibular  space  above  the  lingula.  If 
we  insert  the  needle  along  the  bone  too  far  down,  we  find  that 
a  projecting  lingula  guides  the  needle  directly  into  the  muscle, 
and  this  we  want  to  avoid. 

2.    MENTAL  INJECTIONS 

For  the  injection  into  the  mental  foramen,  we  insert  the 
needle  into  the  reflexion  of  the  mucous  membrane,  below  the 
first  bicuspid.  Holding  the  finger  tip  over  the  foramen,  com- 
press the  mucous  membrane,  and  push  the  needle  down  and 
sliglitly  back  along  the  bone  for  several   millimeters.     AVlien 


Fig.  52.     Radiograph  showing  the  pterygo-mandihular  injection. 


84 


ORAL    ANAESTHESIA 


Pressing 


felt  under  the  finger  inject  into  the  foramen  1  c.c 

while  injecting  will  direct  the  solution  through   the  mental 

foramen  into  the  mandibular  canal.      ( See  Tables  III  and  IV. ) 


Fig.  53.     Radiograph  showing  injection  into  the  mental  foramen. 

3.    BUCCINATOR  INJECTION 

For  the  buccinator  nerve  make  one  injection,  either  directly 
into  the  mucous  membrane  supplied  by  it  or,  in  case  of  inflam- 
mation by  conductive  anaesthesia,  inserting  the  needle  just 
below  the   Stenson's  duct,  pushing  it  backward  toward  the 


LOCAL   ANAESTHESIA  85 


ramus.  The  area  supplied  by  the  buccinator  nerve  varies  in 
different  individuals,  and  it  is  not  always  necessary  to  inject 
for  this  nerve  specially.  Often  it  is  also  reached  with  the 
pterygo-mandibular  injection. 

We  have  studied  the  nerve  supply  in  the  maxil- 
Gonductive  lary  bone  and  found  it  much  more  complicated 
Anaesthesia  than  in  the  mandible.  The  method  to  anaesthet- 
in  the  ize  the  maxillary  nerve  after  it  comes  from  the 

Maxilla  foramen  rotundum  is  very  diflftcult  and  there- 

fore, we  usually  prefer  to  use  two  injections  to 
block  the  sensation  carried  by  the  superior  alviolar  nerves,  and 
two  injections  to  anaesthetize  the  soft  tissue  of  the  palate. 

For  dontal  anaesthesia  use  to  anaesthetize: 

Maxillary  molars  and  bicuspids :  zygomatic  injection. 
Maxillary  incisors  and  cuspids :  infra-orbital  injection. 

For  surgical  anaesthesia   use  to  anaesthetize : 

Posterior  part  of  maxilla :  zygomatic  and  posterior  pala- 
tine injection. 

Anterior  part  of  maxilla :  infra-orbital  and  incisive  injec- 
tion. 

For  large  surgical  operations   use  to  anaesthetize : 
Whole  maxilla :  spheno-maxillary  injection. 

1.    ZYGOMATIC  INJECTION 

Palpitate  the  zygomatic  process  of  the  maxilla,  preparing 
the  place  of  insertion  as  above  and  sliding  the  long  needle, 
keeping  close  to  the  bone,  upward,  backward  and  inward, 
depositing  the  solution  while  injecting.  In  this  manner  the 
two  posterior  superior  branches  and  often  also  the  middle 
superior  branch  are  crossed  by  the  direction  of  the  needle,  and 
anaestlielized  ])y  the  solution,  desensitizing  the  molars  and,  in 
favorable  cases,  also  the  bicuspids.     It  is  often  advisable  to 


86 


ORAL   ANAESTHESIA 


inject  in  two  directions  to  reach  all  the  superior  alviolar 
branches.  The  horizontal  direction  will  reach  the  posterior 
superior  alviolar  branches,  while  the  more  vertical  direction 
will  reach  the  middle  superior  alviolar  nerve,  in  the  case  this 
is  given  off  before  the  maxillary  nerve  enters  the  infra-orbital 
canal.  The  zygomatic  injection  gives  also  anaesthesia  of  the 
buccal  part  of  the  gum.  Inject  2  c.c.  Anaesthesia  occurs  in 
ten  minutes  and  lasts  one  hour.      (See  Tables  III  and  IV.) 


Fig.  54.     Infra-temporal  surface  of  the  maxilla.     The  posterior  superior  alviolar 
branches  are  shown   entering   the  foramina.     One  branch   is  a   gingival  branch. 

2.    INFRA-ORBITAL  INJECTION 

Palpitate  the  infra-orbital  foramen  and  place  upon  it  the 
tip  of  the  thumb  or  index  finger.  With  one  of  the  other  fingers 
retract  the  upper  lip  and  after  preparing  the  place,  insert  the 
long  needle  in  the  canine  fossa,  as  high  as  the  reflection  of  the 
mucous  membrane  allows.  Push  it  along  the  bone  until  felt 
under  the  finger.     While  compressing  the  soft  tissue  over  the 


I-"|(,.   55.     Kadioj^ra])!!   showing   zygrjiiiatic   injection. 


ORAL   ANAESTHESIA 


foramen  with  the  finger,  inject  slowly  and  evenly  1  c.c.  In  this 
manner  the  solution  is  pressed  into  the  infra-orbital  canal 
where  it  reaches  the  anterior  superior  alviolar  nerve.     Anaes- 


FiG.   56.     Infra-orbital  injection  on  the   right  side. 

thesia  occurs  in  the  incisors  and  cuspid.  This  injection  is  only 
indicated  in  alviolar  abscesses  and  larger  surgical  operations. 
(See  Tables  III  and  IV.) 


LOCAL   ANAESTHESIA 


89 


3.    INCISIVE  INJECTION 

If  anaesthesia  of  the  anterior  part  of  the  palate  and  palatal 
gum  is  desired,  we  insert  the  needle  in  the  median  line,  between 
the  two  npper  central  incisors.     Pnsh  it  along  tlie  hone  and  yon 


Fig.   57.     Radiograph   sliowing   Infra-orbital   injection. 


cannot  fail  to  get  into  tlie  incisive  foramen.  A  few  drops  pro- 
duce anaesthesia  in  the  palatal  part  of  the  gum  behind  the  max- 
illary incisors  and  cuspids,  in  five  minutes.      (See  Table  IV.) 


90  ORAL    ANAESTHESIA 

4.  POSTERIOR  PALATINE  INJECTION 

To  get  anaesthesia  of  the  posterior  part  of  the  palate  and 
palatal  part  of  the  gum,  the  needle  is  inserted  near  the  gingival 
margin  of  the  mesial  part  of  the  third  molar  (in  children,  of 
the  last  molar  present.)  Push  it  slightly  upward  and  back- 
ward, till  the  palatal  process  is  reached.  The  main  trunk  of 
the  nerve  passes  forward  in  a  groove  between  the  alviolar  and 
palatal  process,  and  if  the  foramen  is  not  reached  exactly,  we 
are  sure  to  anaesthetize  the  anterior  palatine  nerve.  Inject 
only  a  few  drops ;  if  more  than  0.3  c.c.  is  injected,  anaesthesia  of 
the  soft  palate  occurs,  which  is  undesirable.  The  anaesthesia 
occurs  in  a  few  minutes  and  reaches  as  far  forward  as  the  cuspid 
teeth.     (See  Table  IV.) 

5.  SPHENO-MAXILLARY  INJECTION 

In  large  cases  of  oral  surgery  and  especially  if  the  entire 
region  of  the  maxilla  is  in  a  pathological  condition,  we  can 
take  resort  to  the  spheno-maxillary  injection,  anaesthetizing 
the  whole  second  division  of  the  trigeminal  nerve  in  the  spheno- 
maxillary fossa  after  it  emerges  from  the  foramen  rotundum. 
The  point  of  insertion  is  below  the  junction  of  the  zygomatic 
process  of  the  maxilla  and  the  malar  bone.  Keeping  in  close 
contact  with  the  infra-temporal  surface  of  the  maxillary  bone, 
the  needle  is  advanced  carefully,  obliquely  upwards,  for  four 
centimeters.  (This  injection  requires  a  special  needle  of  larger 
size  and  five  and  one-half  centimeters  in  length,  mounted  most 
advantageously  on  the  bayonet-shaped  piece  in  the  long  hub.) 
Inject  a  small  amount  as  you  go  along  till  you  reach  the  spheno- 
maxillary fossa,  where  the  main  injection  is  made.  The  doses 
should  not  be  too  small,  4  c.c.  of  a  two  per  cent  solution  will 
give  complete  anaesthesia  in  fifteen  minutes.     (See  Table  IV.) 


LOCAL  ANAESTHESIA  91 


D.     GANGLION  ANAESTHESIA 

Haertel*  describes  in  liis  article  some  of  the  largest  surgical 
operations  of  the  face  as  resections  of  the  maxilla,  large  tumor 
operations,  and  also  cases  of  neuralgia,  where  he  used  ganglion 
anaesthesia  of  the  Vth  nerve  with  great  success,  either  with 
Novocain  or  in  neuralgia  with  alcohol.  The  anaesthesia  was 
mostly  produced  on  both  sides  by  a  double  injection. 


Fig.  58.     Schematic  drawing  showing  the  injection  into  the  Gasserian  Ganglion. 

INJECTION  INTO  THE  GASSERIAN  GANGLION 

Insert  the  needle  in  the  cheek  (after  preparing  the  place 
in  the  usual  manner)  opposite  the  gingival  margin  of  the  second 
maxillary  molar,  after  anaesthetizing  the  tissue  superficially, 
push  the  needle  upward  between  the  upper  jaw  and  ramus  of 
the  mandible  till  it  reaches  the  base  of  the  skull  striking  the 
l»l;iiiiiiii  infratemporale.  While  inserting  the  needle  we  place 
the  index  finger  of  the  left  hand  into  the  superior  part  of  the 
vestibuliim  oris  to  prevent  the  needle  from  piercing  the  mucous 
membrane  of  the  mouth.  After  having  reached  the  base  of  the 
skull,  the  direction  of  the  needle  is  adjusted  by  the  following 
rules:  If  we  look  at  it  from  front,  we  find  that  it  points  in  the 

*   Haifrlel:    KortHi-liritic   aiif   <liiii    (iebioto   dcr    Local    A  iiaesthesie.    Zeitschrift    fuer    aerztlicho 
Fortbildiing.      1914.    1. 


92 


ORAL   ANAESTHESIA 


direction  of  the  pupil  of  the  eye  of  the  same  side,  and  if  we  look 
at  it  from  the  side  it  points  towards  the  tubereulum  articulare 
of  the  zygomatic  arch.  Feeling  our  way  forward  along  the 
bone  we  reach  the  third  division  of  the  fifth  nerve,  where  it 
emerges  from  the  foramen  ovale.  The  patient  will  give  a  sign 
of  pain  when  the  nerve  is  reached.     The  distance  up  to  this 


Fig.  59.     Foramen  ovale  in  the  skull  seen  from  the  position  of  the  operator. 


point  is  five  to  six  centimeters.  Now  the  needle  is  inserted 
one  and  one-half  centimeters  into  the  substance  of  the  ganglion. 
Inject  1  c.c.  of  a  two  per  cent  solution  of  Novocain  containing 
0.000,02  gram  of  Suprarenin  to  1  c.c.  Scrupulous  asepsis  is 
of  greatest  importance. 


VIII.    FAILURES  AND  ILL- 
EFFECTS  IN  LOCAL 
ANAESTHESIA 

Although  failures  iu  general  anaesthesia  might  have  grave 
results,  failures  in  local  anaesthesia  do  not  endanger  the  pa- 
tient's life  as  long  as  the  maximal  dose  is  not  reached.  If  we 
consider  the  ability  local  anaesthesia  gives  us  to  improve  the 
quality  of  our  work,  saving  the  patient  suffering  at  the  same 
time,  and  the  possibility  to  do  away  with  the  dangers,  handi- 
caps, discomforts,  and  after-effects  of  general  anaesthesia  for 
exodontia  and  minor  surgical  operations  in  the  oral  cavity,  the 
small  percentage  of  failures  forms  a  negligible  factor,  which 
can  be  almost  entirely  eliminated  with  perfected  technique, 
reliable  anaesthetics  and  careful  elimination  of  infection  during 
and  after  the  operation.  We  meet  failures  and  ill-effects  in 
local  anaesthesia  of  various  kinds: 

A.  True  failures  and  ill-effects. 

B.  Psychological  effects. 

C.  Ill-effects  due  to  other  sources. 

Failures  and  ill-effects  very  frequently  occur 
True  Failures  not  from  the  injection,  but  from  the  psychic 
andlll-Eftects      attitude   of  the   patient,    or    other    causes, 

wliicli  we  will  consider  later.  True  failures 
can  be  classified  as  follows: 

a.  No  or  insufficient  anaesthesia  is  obtained. 

b.  Undesiralde  symptoms  during  anaesthesia. 
C.      Aftf-r-effccts. 

a.     No  anaesthesia  is  obtained.      This     can     be    entirely 
eliminated,  if  (Ik;  cause  is  ascertained.     If  no  anaesthesia  oc- 


94  ORAL   ANAESTHESIA 

curs,  if  it  is  not  sufficiently  deep,  or  if  it  does  not  last  long 
enough,  we  can  repeat  the  injection,  avoiding  the  second  time 
the  probable  error.  In  the  infiltration  method  it  is  important 
to  use  the  same  puncture,  not  only  to  avoid  unnecessary  dam- 
age to  the  mucous  membrane,  but  also  because  the  solution 
might  be  lost  through  the  first  puncture,  if  a  second  one  is 
made  close  by.     Failures  of  result  usually  come  from: 

1.  Insufficient  knowledge  of  the  anatomy  of  the  oral  cavity. 

2.  Insufficient  apparatus  or  technique.  The  anatomy  and 
technique  should  be  clearly  in  the  mind  of  the  operator.  After 
some  practice  these  sources  of  failure  are  soon  eliminated.  In 
the  infiltration  method  the  most  frequent  causes  are,  if  the  part 
opposite  the  apex  of  the  root  is  not  reached,  or  if  the  contact 
with  the  bone  is  lost.  In  conductive  anaesthesia,  if  we  inject 
into  muscle  tissue  instead  of  .into  the  connective  tissue  sur- 
rounding the  nerve  trunks.  This  is  especially  true  in  the 
pterygo-mandibular  injection,  where  we  are  sure  to  infiltrate 
the  internal  pterygoid  muscle,  if  we  lose  the  contact  with  the 
ramus  or  insert  the  needle  too  low.  In  the  case  where  we  are 
too  low  down,  we  slide  over  the  lingula  into  the  muscle,  this 
should  be  avoided.  The  insertion  should  be  made  one  centime- 
ter over  the  last  molar,  this  is  above  the  lingula. 

3.  Inefficient  drugs  or  drugs  deteriorated  through  age, 
chemical  or  bacteriological  influences.  If  the  solution  shows  a 
slight  pinkish  color  it  is  a  sign  of  changes  that  have  taken  place. 
Anything  that  deteriorates  the  drugs  decreases  their  anaes- 
thesia producing  power.  Tlie  anaesthetic  should  be  fresh  and 
the  solution  water  clear. 

4.  Too  large  percentage  of  suprarenin  is  liable  to  interfere 
with  the  infiltration  of  the  center  of  thick  nerve  trunks,  on  ac- 
count of  its  astringent  properties. 

b.     Undesirable  symptoms  during  the  anaesthesia.     It   is 

hard  sometimes  to  distinguish  whether  such  symptoms  are  due 


FAILURES  AND  ILL-EFFECTS  95 


to  psychological  effects,  or  to  the  anaesthetic.     In  this  chapter 
we  will  consider  the  latter: 

LOCAL  SYMPTOMS 

There  is  pain  experienced  during  the  injection.  This  is 
due: 

1.  From  injecting  a  too  cold  or  hot  solution.  The  solution 
ought  to  be  of  blood  temperature.  This  can  be  easily  obtained 
by  my  described  method,  where  the  solution  is  specially  pre- 
pared every  time  before  use. 

2.  From  drugs  (antiseptics)  added  to  the  solution  to  keep 
the  solution  sterile.  Seidel  found  in  applying  the  velum  test 
on  the  cutis  of  the  arm  that  thymol  added  to  solution  produces 
in  some  cases  severe  pain. 

3.  From  the  solution  not  being  isotonic  with  the  blood,  too 
liigh  or  too  low  a  percentage  of  salt  causes  osmotic  pressure. 

4.  From  injecting  into  an  acute  abscess,  this  should  be 
avoided  from  obvious  reasons. 

GENERAL  SYMPTOMS 

The  heart  action  may  be  increased,  sweating  may  occur  or  a 
queer  feeling  in  the  extremities.  If  these  are  not  of  psycho- 
logical origin  they  can  only  come  from: 

1.  Tlie  suprarenal  substances.  In  the  beginning  I  used 
adrenolin  solution  1:1000,  whicli  of  course  deteriorates  much 
quicker  than  the  synthetic  suprarenin.  I  injected  into  one 
patient  a  solution  of  two  per  cent  Novocain,  and  three  drops  of 
Adrenolin  to  1  c.c.  After  only  injecting  0.2  c.c.  for  a  maxillary 
cuspid,  tlie  above-mentioned  symptoms  appeared  in  extreme 
degree,  cold  sweating  and  muscular  pains  lasted  two  hours.  I 
credit  the  cause  to  toxic  effects  from  the  adrenolin,  which  I 
received  fresh  from  the  drug  store.  It  was  slightly  discolored. 
Since  using  synthetic  sui)rarenin  I  have  had  no  more  such 
grave  experiences,  but  in  some  patients  I  observed  every  time 


96  ORAL   ANAESTHESIA 

slight  effects  of  sweating  on  the  forehead  or  qneer  feeling  iu 
the  fingers.  I  credit  this  to  too  high  percentage  of  Suprarenin 
contained  in  the  E  tablets,  and  have  therefore  asked  for  the 
manufactnring  of  a  new  tablet,  which  I  recommend  for  all  nor- 
mal cases.  This,  the  T  tablet,  contains  only  0.000,02  gram 
Synthetic  Snprarenin  to  1  c.c. 

Potassium  bromide  or  "valyl"  highly  recommended  by  Pro- 
fessor Kionka,  in  Breslan,  may  be  given  in  these  cases.  The 
latter  is  valuable  in  cases  of  increased  pulse  and  heart  action 
and  trembling.  It  also  can  be  given  as  a  preventive,  one- 
quarter  to  one-half  hour  before  the  operation,  to  counteract 
nervousness. 

In  cases  of  fainting,  tip  the  patient's  head  between  his 
knees,  give  aromatic  spirits  of  ammonia,  strong  black  coffee,  oil 
of  camphor,  or  strychnine  sulphate.  Some  of  these  agents 
should  always  be  kept  handy.  Black  coffee  is  a  splendid  stimu- 
lant on  account  of  its  lasting  action. 

c.  After-effects.  We  must  consider  that  after-effects  fre- 
quently occur  after  operation  or  extraction,  from  other  reasons 
than  the  injection.  These  will  be  considered  in  another  chap- 
ter.    After-effects  are  oedema  and  after-pain. 

Oedema.  This  is  a  simple  swelling  caused  by  infiltration 
of  serum.     It  may  be  caused  : 

1.  By  solutions  which  are  not  isotonic.  By  traumatism, 
caused  by  inserting  the  needle  several  times  in  the  same  part, 
correcting  the  direction.  In  conductive  anaesthesia,  by  pierc- 
ing the  inferior  pterygoid  muscle  or  injecting  into  the  same. 
This  also  may  cause  ankylosis  of  the  mandibula  and  difficult 
deglutition. 

2.  Through  toxic  or  irritating  effects  upon  the  protoplasm 
from  deteriorated  drugs,  antiseptics  or  other  unnecessary  addi- 
tions to  the  anaesthetic  solution.  Also  to  large  percentage  of 
Suprarenin  in  very  sensitive  tissue. 


FA  ILL' RES  AND  ILL-EFFECTS  97 

3.  From  iujection  into  muscles.  Although  an  anaesthetic 
solution  is  absorbed  quickly  and  without  disturbance  from 
connective  tissue,  if  the  percentage  of  suprarenin  is  not  too 
high,  it  is  a  ditferent  question,  however,  if  muscles  are  infil- 
trated. Here  the  absorption  is  sluggish,  and  takes  sometimes 
two  or  three  davs.  This  may  cause  swelling.  In  conductive 
anaesthesia  of  the  mandible,  there  is  great  danger  to  inject  into 
the  internal  pterygoid  nuiscle,  which  causes  swelling  and  often 
also  false  ankylosis  and  difficult  deglutition. 

Oedema  not  complicated  by  infection  will  disappear  with- 
out treatment. 

After-pain.  In  treating  pain  after  injections,  we  have  to 
consider  that  post-operative  pain  frequently  occurs  from  causes 
which  have  nothing  to  do  with  the  injection.  These  are  consid- 
ered later.  Pain  from  the  injection  can  only  be  ascertained 
after  a  purely  dontal  operation.  After-pain  very  seldom  occurs 
from  the  injection.     Causes  are: 

1.  Deteriorated  drugs. 

2.  Unnecessary  additions  to  the  solution,  such  as  anti- 
septics. 

3.  Infection  from  non-sterile  solution,  syringe  or  needle. 

4.  Infection  taken  up  by  the  needle,  from  the  mucous  mem- 
brane or  fluids  of  the  mouth. 

.").     Infection  of  the  puncture  during  the  anaesthesia. 
(;.     Infection  of  the  puncture  after  the  operation, 

PROLONGED  ANAESTHESIA 

Cases  of  prolonged  anaesthesia  have  been  reported  lasting 
for  several  days  or  weeks.  These,  however,  can  always  be 
traced  to: 

].  Injury  of  a  nerve  during  operation,  as  in  tlie  lower  jaw, 
if  the  tooth  sockets  come  in  contact  with  the  mandibular  canal. 
KsjX'cially  in  impacted  wisdom  teeth,  there  is  danger  of  injur- 
ing the  inferior  alviohii*  nci've. 


98  ORAL   ANAESTHESIA 

2.  Injury  of  the  mandibular  canal.  Loosening  a  piece  of 
bone  whicb,  if  pressed  downward,  can  cause  anaesthesia  by 
pressing  upon  the  nerve. 

3.  Injecting  of  alcohol  causes  prolonged  anaesthesia,  it  is 
therefore  important  to  remove  the  alcohol  carefully  from  the 
syringe  and  dissolving  cups. 

In  nervous  and  hysteric  persons,  the  patient's 

Psychological    mind  and  imagination  plays  a  great  part  in 

Effects  the  success  of  the  injections  and  operator,  and 

it  is  well  to  say  a  few  words  in  regard  to  the 

attitude  of  the  operator  towards  the  patient. 

We  get  so  accustomed  to  our  work  that  we  neglect  to  realize 
the  fear  and  terror  some  sensitive  patients  experience  previous 
to  an  operation.  We  forget  that  many  people  make  it  their  pas- 
time to  talk  about  nothing  else  but  symptoms,  cures  and  opera- 
tions of  diseases,  and  that  some  are  walking  encyclopedias 
of  the  ill-effects,  accidents,  or  after-effects  of  drugs,  and  spread 
their  knowledge  among  their  friends.  Some  associate  every 
syringe  with  cocaine,  and  are  terrified  of  cocaine  poisoning, 
and  others  are  alarmed  by  the  numbness  produced  by  an  anaes- 
thetic, confusing  it  with  paralysis. 

Sometimes  the  respiration  is  increased,  and  the  patient  per- 
spires on  the  forehead.  This  very  frequently  is  fear,  and  often 
is  seen  after  insertion  of  the  needle  before  a  drop  is  injected. 

The  best  example  is  one  of  the  cases  I  demonstrated  on  at 
the  Massachusetts  State  Society  Meeting  of  1913.  While  ex- 
plaining the  technique  of  the  injection  to  the  audience,  the  pa- 
tient, a  mail-carrier  of  about  30-35  years,  collapsed.  I  had  not 
made  any  injection,  but  the  patient,  which  was  weakened  from 
severe  pain,  collapsed  from  fear  caused  by  the  explanation  and 
description  of  the  operation. 

Dr.  Frohman  had  a  case  for  extraction  of  two  wisdom  teeth, 
with  somewhat  similar  experience.  Only  that  the  patient 
fainted  after  the  injection;  he  succeeded,  however,  in  extracting 


FAILURES  AND  ILL-EFFECTS  99 

one  wisdom  tooth,  and  when  the  patient  came  back  (after  two 
weeks)  for  extraction  of  the  other  wisdom  tooth,  he  hesitated 
to  give  an  anaesthetic.  He  nsed  the  ethyl-chloride  spray  for 
a  very  short  time,  and  at  once  the  same  symptoms  appeared. 

It  is  fear  which  we  have  to  conquer,  in  all  these  cases,  and 
the  antidotes  are,  convincing  attitude,  sureness  of  result,  confi- 
dence of  the  operator  in  himself,  and  in  his  success,  which  will 
result  in  confidence  of  the  patient  towards  the  operator.  It  is 
well  to  tell  the  patient  that  Novocain  has  absolutely  nothing 
in  common  with  cocaine  and  is  entirely  harmless.  Tell  them 
what  parts  are  going  to  feel  numb,  so  that  this  does  not  alarm 
tliem. 

Post-operative    pain    and    inflammation    may 
Ill-Effects  occur  after  an  operation,  not  caused  by  the 

Due  to  Other  injection  but  directly  from  the  wound.  It  can 
Sources  come: 

1.     From  a  septic  wound. 

2.  From   a    wound    infected    during    the  operation. 

3.  From  a  wound  infected  after  the  operation  by  the  fluid 
of  the  oral  cavity.  A  wound  in  the  mouth  cannot  be  kepi 
aseptic,  and  is  exposed  to  secondary  infection. 

To  avoid  this  inflammation  and  pain  after  operations,  in- 
fected tooth  sockets  should  be  curetted  and  washed  out  with  an 
antiseptic  solution.  Also  the  suprarenin  should  not  be  admin- 
istered in  the  anaesthetic  in  too  high  percentage,  because  the 
danger  of  infection  is  increased  through  too  deep  anaemia. 
For  normal  cases  0.000,02  gram  Suprarenin  to  1  c.c.  is  suffi- 
cient, allowing  enough  bleeding  to  protect  the  wound. 

Tlie  severest  part  of  post-operative  pain  is  usually  elim- 
inated by  the  long  duration  of  tlie  anaesthesia.  Dressing  the 
wound  witlj  gauze  containing  Novocain  powder,  after  thor- 
uiiuli  ciu'clliiig  will  be  roinid  bciicliciMi,  still  better  is  Tribel's : 

I^     (Milonil-liydrat   2.0 

(Jamplior 1.0 

Novocain    0.5 

Misce  exactissinie 


100  ORAL    ANAESTHESIA 

or  Eiiroform  paste : 

19     Orthoform    40.0 

Europhen    60.0 

Liquid  petroleum s.  q.  to  make  paste 

Internally  administer  :  Trigeminin,*  Aspirin  or  Pyramidon.* 
Failure    and    ill-effects    therefore    can    almost    always    be 
traced  back  to  the  incorrect  technique  of  deteriorated  drugs, 
infection,  and  fear.     And  these  can  be  eliminated  almost  en- 
tirely. 

I  have  used  local  anaesthesia  in  children,  and  in  adults  up 
to  eighty,  in  patients  which  collapsed  from  cocaine,  and  which 
have  been  warned  not  to  have  another  injection,  and  I  have 
repeatedly  used  it  on  patients  with  severe  heart  and  jHilmonary 
disorders  of  all  kinds,  with  excellent  result,  and  I  have  the  full 
appreciation  of  the  patients. 

*   Farbwerke   Hoechst   Co.,    Ill    Hudson    Street,    New   York. 


IX.  PRACTICAL  APPLICA- 
TION OF  LOCAL  ANAES- 
THESIA IN  DIFFERENT 
BRANCHES  OF  DENTISTRY 

The  various  operations  which  can  be  performed  under 
"Local  Anaesthesia''  have  been  mentioned  shortly  in  a  previous 
chapter.  To  make  it  clearer  Avhat  special  method  is  best 
adapted  for  a  certain  case,  and  to  bring  out  variations  benefi- 
cial for  certain  cases,  the  author  adds  this  chapter.  It  also  is 
intended  to  be  of  a  more  practical  nature,  suggesting  opera- 
tions, as  the  amputation  of  roots,  which  through  local  anaes- 
thesia are  brought  into  the  realm  of  the  general  practitioner. 
Two  general  rules  for  selecting  the  method  of  injection : 

1.  Use  always  the  simplest  and  surest  method. 

2.  Avoid  injecting  into  pathological  tissue. 

Tlie  four  following  tables  show  what  teeth,  and  what  tis- 
sue, we  can  anaesthetize  Avith  tlie  infiltration  and  with  the  con- 
ductive method: 


TABLE  I.    INFILTRATION  ANAESTHESIA  FOR  THE  TEETH  ONLY 


1  MAXILLA 


BUCCAL 


LABIAL 


BUCCAL 


*  NOT  ALWAYS  SUCCESSFUL 
ON  ACCOUNT  or  THICKNESS 
OF  BONE. 


EMANDIBULA 


BUCCAL 


LABIAL 


(not  successful) 


VS9     w}    (P<f9     fe 


BUCCAL 


(not  successful) 


mK.  m    IM.  UB     IB       C.  _L  .      £.     C.      L.  C.      IB.   TTB-     IM.  IM.  ITM. 

(not    NE.EOED.) 


LINGUAL 


TABLE  11.     INFILTRATION  ANAESTHESIA  OF  THE  TEETH 

AND  SOFT  TISSUES 


INAXILLA 


BUCCAL 


LABIAL 


BUCCAL 


^@©©   ©   ©©©©©©  ©   (iB@®® 

EM    m*  m*    15       IB        C       L        C        C        L       C        IB       IB      in*    I11*¥M 

S  (iS  w  (3 


PALATAL 


n  NAIVDIBULA 


*  NOT  ALWAYS  SUCCESSFUL 
ON  ACCOUNT  OP  THICKNESS 
or  BONE. 


bUCCAL 


LABIAL 


(not  successful) 


in    im    m    hb    ib    c 


(^    (^    (^    ^5 
L        C        C       L. 

(PM      (Ccc 


BUCCAL 


(not         successful) 


C     IB    IB    m  in  in 


LINGUAL 


TABLE   III.    CONDUCTIVE  ANAESTHESIA  OF  THE 

TEETH  ONLY 

I.MAX1LLA 


Right  right  le.ft  left 

zygomatic    infraorbital  infraorbital  zygomatic 


'iKt.IM.  m.  HB.   IB.'    C.    L.      C.     C.     L.      C.    'iB.  IB.  IM.  IM. 


inM. 


n.NANDIBULA 


RIGHT  LETT  RIGHT  LEFT 

PTERYGOMANDIBULAR     MENTAL  FORAMEN  MENTAL  FORAMEN        PTERYGOMANDIBULAR 


TABLE  IV.    CONDUCTIVE  ANAESTHESIA   OF  THE   TEETH 

AND  SOFT  TISSUES 

1.  MAXILLA 


RIGHT  RIGHT  RIGHT  LEFT  LEFT  LEFT 

SPHENO-mXlLLARY  ZYGOMATIC    INFRAORBITAL      INFRAORBITAL      ZYGOMATIC     bPffiNO-rWUlMY 


OR 

ENTIRE-    nAXlLLA 


D.MANDIBULA 


RIGHT 

LEFT 

RIGHT 

PTERYGOMANDIBULAR 
AND  LINGUAL 

MENTAL  F. 

MENTAL  F. 

LEFT 
PTERYGOMAHDIBU  LAR 
AND    LINGUAL 


106  ORAL   ANAESTHESIA 

1.     OPERATIVE   DENTISTRY 

To  remove  caries  and  prepare  cavities  with 
Cavity  normal  pulps,  for  fillings,  we  need  usually 

Preparations       anaesthesia  of  the  teeth  only.     But  if  the 

gum  has  to  be  retracted  for  cervical  cavities, 
anaesthesia  of  the  gum  is  advisable  to  allow  the  proper  adjust- 
ment of  the  clamp. 

The  first  and  second  maxillary  molars  sometimes  do  not 
respond  to  the  infiltration  method,  especially  in  patients  with 
massive  bone  formations.  If  the  zygomatic  process  extends 
far  down,  it  prevents  the  infiltration  of  these  teeth  from  the 
buccal  side;  in  these  cases  conductive  anaesthesia  by  the  zygo- 
matic method  is  advisable.  If  the  infiltration  method  has  been 
used  and  proves  a  failure,  apply  the  conductive  method  at  once. 
If  two  or  three  adjoining  teeth  need  to  be  anaesthetized,  use  the 
horizontal  injection,  proceeding  from  one  tooth  to  the  other 
without  removing  the  needle. 

The  lower  molars  and  bicuspids  cannot  be  anaesthetized 
singly,  the  few  pores  around  the  alviolar  margin  are  not  suffi- 
cient to  assure  deep  enough  anaesthesia,  the  success  is  too 
uncertain  to  make  it  practical.  If  there  is  a  cavity  in  an  in- 
cisor in  addition  to  cavities  in  the  posterior  teeth  of  the  same 
side,  use  the  conductive  anaesthesia  up  to  the  median  line,  and 
though  the  pulp  might  not  be  entirely  anaesthetized  in  the 
incisors,  on  account  of  the  anastomosis,  the  dentine  usually  is 
desensitized  to  allow  cavity  preparation.  Should  the  anaes- 
thesia be  unsatisfactory,  inject  by  the  infiltration  method  into 
the  mental  fossa,  this  will  anaesthetize  the  incisor  tooth  in 
question  completely,  in  five  minutes.  The  waiting  time  of  fif- 
teen minutes  seems  objectionable  to  some  men,  but  it  should  be 
remembered  that  this  is  made  up  easily  because  the  anaesthesia 
allows  us  to  work  much  quicker  afterwards.  If  there  are  sev- 
eral cavities  on  one  side  they  can  be  prepared  in  one  sitting, 
and  the  most  anterior  one  should  be  taken  first,  because  the 


PRACTICAL  APPLICA TION  OF  LOCAL  ANAESTHESIA    107 

anaesthesia  begins  in  front  and  works  backward.  Three,  fonr 
or  five  teeth  sometimes  can  be  prepared  for  fillings  with  one 
injection.      (Tables  I  and  III.) 

When  preparing  a  cavity  for  a  filling  under  anaesthesia,  we 
should  be  careful  that  the  tooth  does  not  heat  up,  thermal 
shocks,  though  not  felt  by  the  patient,  may  burn  the  delicate 
pulp  tissue,  cause  inflammation  and  subsequently  a  dead  pulp. 
Also  one  should  bear  in  mind  the  anatomy  of  the  tooth  because 
we  have  put  asleep  the  guard  pain,  which  gives  us  warning 
when  we  approach  the  pulp-chamber.  The  pulp-chamber  in 
young  patients  is  of  large  size,  it  decreases  with  age,  and  in 
pyorrhetic  and  gouty  patients,  it  sometimes  has  receded  under 
the  gum  line. 

If  the  cavity  is  extensive,  it  is  of  great  value  to  ascertain  the 
outline  of  the  pulp-chamber  by  the  radiograph,  and  in  all  cases 
it  is  well  to  seal  the  dentinal  tubules  with  carbolic  ether  rosin 
after  the  cavity  preparation  is  completed.  This  will  prevent 
irritation  from  the  filling,  be  it  permanent,  with  or  without 
cement  lining,  or  be  it  temporary.  In  the  latter  case  we  also 
have  the  danger  of  infection,  if  the  filling  gets  loose  or  is  partly 
chewed  out.  Besides  protecting  the  cavity  rosin  eliminates 
also  the  pain  caused  by  the  cement  when  the  permament  filling 
(inlay)  is  set. 

To  remove  a  normal  pulj),  the  anaesthesia  is 
Removal  of  accomplished  in  the  same  manner  as  described 
Normal  Pulps  for  cavity  preparations   (Tables  I  and  III). 

Sometimes  from  some  reason  or  other  we  do 
not  get  complete  anaesthesia  of  the  pulp,  especially  when  anaes- 
thetizing the  lower  teeth  with  the  conductive  method.  Not 
making  a  special  injection  for  the  incisors,  we  find  that  the 
pulp  can  be  exposed,  but  on  account  of  the  anastomosis  from 
the  otiier  side,  it  is  still  somewhat  sensitive.  In  these  cases 
the  anaestlu'sia  is  (•(unpjctcd  surprisingly  easy  by  pressure 
anaesthesia.     Place  half  of  a  pugglet  of  Novocain  over  the  ex- 


108 


ORAL   ANAESTHESIA 


Fig.  60.     Radiograph  of  maxillaiy  incisors  showing  variation  of  the  pulp  cham- 
ber.    Note  how  the  pulp  recedes  in  the  region  of  decay. 


1 

1 

f 

Fig.  61.     Radiograph  of  cuspids.     Note  the  open  apical  foramen  in  No.  1,  and 
the  division  of  the  root  canal  in  No.  4. 


Fig.  62.     Radiograph  of  maxillary  first  bicuspids.     Note  large  apical  foramen  in 

the  young  tooth  No.  4. 


Fig.  63.     Radiograph  of  maxillary  second  bicuspids.     Note  variations  of  the  root 
canals.     No.  1  with  open  apical  foramen.     No.  3,  showing  two  apical  canals. 


PILiCTICAL  APPLICA TION  OF  LOCAL  ANAESTHESIA    109 


Fig.    64.     Radiograph    of    maxillary    molars.     Normal    pulp   chamber    in    No.    1. 

Almost  entirely  calcified  pulp  chamber  in  No.  2.     Two  apical  canals  in  the  palatal 

root  of  No.  3.     Bent  buccal  root  in  No.  4. 


A 


Fig.  65.     Radiograph  of  mandibular  incisors.     Note  variations. 


f!lt 


Fig.  66.     Radiograph  of  mandibular  bicuspids,  showing  many  abnormalities. 


tRfff 


Fig.    67.     Radiograph    uf    mandibular    molars.        No.    1,   young   tooth   with   open 
foramen.     No.  3   and  4   show   calcified   pulp   chambers. 


110 


ORAL   ANAESTHESIA 


posure,  do  not  add  water  but  let  it  dissolve  in  the  moisture 
secreting  from  the  pulp.  When  it  has  become  of  the  consist- 
ency of  a  paste,  press  it  down  w  ith  unvulcanized  rubber.  No 
pain  is  caused  and  the  action  occurs  at  once. 

When  extracting  the  pulp  one  must  realize  that  also  the 
tissue  around  the  tooth  is  anaesthetized,  and  should  be  careful 
not  to  injure  the  tissue  beyond  the  apical  foramen,  this  often 
causes  peridontitis.  Insert  the  broach  to  the  end  of  the  root 
canal  and  extirpate  the  pulp.  Use  sulphuric  acid  or  sodium 
potassium  treatment  to  remove  all  organic  tissue  from  side 
canals  and  accessory  foramina.  The  root  canals  should  not  be 
filled  the  same  sitting  unless  one  ascertains  the  procedure  and 
completion  of  the  filling  with  a  liberal  amount  of  radiographs. 
On  account  of  the  anaesthesia  the  cooperation  of  the  patient 
is  lost,  and  we  have  no  giiide  to  tell  us  when  the  filling  has 
penetrated  through  the  apex. 


Central  incisor  with  chronic  abscess   (lead  filling),  lateral  incisor  with  pulpitis.     Infiltration 
method  was  used  to  extirpate  the  pulps. 


PRACTICAL  APPLICA  TION  OF  LOCAL  ANAESTHESIA    1 1 1 


In  some  patients  all  the  teeth  have  a  great 
Removal  of  amount  of  secondary  dentin  deposited  in  the 
Calcified  Pulps  root   canals,    which   are   sometimes    entirely 

obstructed,  the  circulation  is  interfered  with, 
but  nerve  libers  extend  throughout  the  pulp  chamber.  It  is 
impossible  to  anaesthetize  a  pulp  of  that  sort  with  pressure 
anaesthesia,  also  arsenic  preparations  are  most  frequently  un- 
successful. Local  anaesthesia  is  ideal  for  these  cases  and, 
guided  by  a  radiograph,  we  can  open  them  up  to  the  apex  with 
root  canal  instruments  and  drugs  or  both  combined.  The 
method  of  anaesthesia  is  the  same  as  above. 


Fig.  69.     Rool  of  lower  .second  hicu.spid.     Its  lower  end  was  extremely  sensitive 

and   inaccessible.     Conductive  anaesthesia   was   used   to   ream   the   root   canal   to 

tne  ape.x.     1  he  hrst  bicuspid  shows  the  same  condition  but  is  complicated  on 

account   of   a   badly   bent    root. 

Another  case  where  pressure  anaesthesia  is  un- 
Removal  of  successful  is,  if  obliteration  of  the  root  canals 
Pulps  with  or  pulp  chamber  lias  taken  place.  These  are 
Pulp  Stones     ascertained  with   the  radiograpli  and   removed 

under  local  anaesthesia. 

Oflen  and  iiiosl  fr('(|ii('iitly  in  the  six-year 
Removal  of  mohirs  of  children  who  neglected  their  teeth, 

Hypertrophied  w<'  iind  Ihc  pulp  hypci-li-c.phicd  and  cxI ending 
f*"'ps  way   out   of   the   ])nlp   chamber.     The    blood 

supply  is  increjised  :ind  sensitiveiu'ss  jn-evails 
in  lh<;  root  canals.      Injecl   by  Ihe  inliKnilion  method,  wliich  is 


112  ORAL   ANAESTHESIA 

preferable  whenever  it  can  be  applied,  but  use  the  E  tablet 
with  0.000,05  gram  of  Sujjrarenin  to  1  c.c.  In  the  lower  pos- 
terior teeth  j)roduce  anaesthesia  with  the  conductive  method, 
using  the  T  tablet,  and  after  anaesthesia  has  occurred  inject 
solution  made  with  the  E  tablet  directly  into  the  pulp.  The 
high  i3ercentage  of  Suprarenin  in  the  E  tablet  causes  anaemia. 
This  is  the  only  operation  in  operative  dentistry  where  we  wish 
to  combine  anaesthesia  with  anaemia.  Remove  the  hypertro- 
phied  pulp  and  cauterize  if  necessary. 

If  the  inflammation  of  the  pul]3  has  not  gone  be- 
Removal  of  yond  the  apical  foramen,  anaesthesia  is  produced 
Inflamed  as  for  normal  pulps.  (Tables  I  and  III.)  The 
Pulps  pain  will  stop  as  soon  as  the  anaesthesia  occurs. 

The  pulp  then  is  removed  under  great  care  not  to 
infect  the  area  beyond  the  foramen.      (Fig.  68,  lateral  incisor.) 

The  peridontal  membrane  is  inflamed,  the 
Removal  of  tooth  feels  long,  and  pain  is  increased  if  the 

Inflamed  Pulps  tooth  is  touched.  The  outer  j)late  of  the 
Complicated  by  alviolar  process  has  not  yet  been  affected. 
Periodontitis  Inject    by    the    infiltration    or    conductive 

method  (Tables  I  and  III).  The  pain  will 
stop  and  the  root  canal  can  be  opened. 

The  alviolar  plate  is  usually  destroyed,  sinus 
Acute  Alviolar  may  be  present  or  not,  which  usually  deter- 
Abscess  at  mines  the  amount  of  pain.     The  infiltration 

the  Apex  method  in  these  cases  is  contra-indicated  on 

account  of  the  danger  of  deep  infection,  and 
producing  of  pain  through  increased  pressure.  Many  writers 
recommend  to  inject  around  the  periphery  of  the  abscess,  but  it 
is  not  necessary  to  take  this  chance,  as  we  get  best  results  with 
the  conductive  methods.  (Table  IV.)  The  area  of  infection 
can  usually  be  entirely  avoided.     The  palatal  and  lingual  gum 


PILiCTICAL  APPLICA  TIOX  OF  LOCAL  ANAESTHESLi    113 

needs  ouh'  to  be  anaesthetized  if  the  abscess  points  towards 
the  palatal  or  lingual  part  of  the  montli.  In  acute  alviolar 
abscesses,  we  produce  an  artificial  sinus,  and  establish  the  pos- 
sibility of  thorough  irrigati<ui  from  the  tooth  through  the  apex 
and  sinus  to  the  nioutli.  This  is  easily  done  under  local  anaes- 
thesia. 


Fig.  70.     Acute  alviolar  abscess  of  a  central  incisor.     The  tooth  was  verj^  loose 

and  very  painful  on  percussion.     Nasal  anaesthesia  was  used  to  open   into  the 

pulp  chamber  and  lance  the  abscess. 


In  chronic  alyiolar  abscesses  there  is  usually 
Chronic  Alvi-  no  sensation  in  the  tooth,  and  the  treatment 
olar  Abscess  can  be  applied  to  tln^  root  canal  without 
anaesthesia.  Very  frequently,  however, 
there  is  a  graniilniii  at  the  apex  wliich  (h)es  not  always 
yield  treatment  from  the  root  canal,  and  has  to  be  remoyed 
surgically.  If  it  is  treated  from  the  root  canal  there  is  usually 
no  need  of  anaesthesia,  except  the  tooth  be  sensitive  on  percus- 
sion. The  surgical  treatment  consists  in  opening  up  and  cur- 
etting the  apex  of  the  tooth  and  cavity  thoroughly.  Amputa- 
tion of  the  apex  of  the  root  is  only  necessary  if  it  is  infected, 
partly  absorbed  or  gangreiions. 

Usually   tliere  is  little  inflaniination    and    the   infection    is 
confined    to   the  i-egion   of   the  a|»e.\'   of  the  alviolns.      In    these 


114 


ORAL    ANAESTHESIA 


cases  the  infiltration  method  can  be  used,  and  anaesthesia  can 
be  produced  as  in  Table  II.  In  cases  where  the  inflammation 
covers  a  larger  field,  the  conductive  method  is  preferable, 
(Table  IV.) 


Fig.  71.  Chronic  alviolar  abscesses.  No.  1  shows  chronic  abscess  on  first  and 
second  bicuspid.  No.  2  shows  chronic  abscess  on  left  central  carrying  a  bridge. 
Right  central  pulp  chamber  almost  entirely  calcified,  filling  extending  into  middle 
of  tooth,  abscess  on  the  apex.  Right  lateral  shows  also  a  chronic  abscess. 
Patient  suffers  of  rheumatism.  No.  3.  Chronic  abscess  on  second  bicuspid. 
Small  cyst  on  six-year  molar.    Teeth  feel  lame  from  time  to  time. 

Abscesses  are  not  always  originated  from  in- 
Pericemental  fected  pulps,  but  often  occur  on  the  side  of  the 
Abscess  root  from  pockets,  perforations  or  foreign  ma- 

terial. These  have  to  be  curetted  and  cleaned, 
which  is  a  painful  process  and  should  be  done  under  local 
anaesthesia.  The  gum  only  needs  to  be  anaesthetized,  after 
Table  II  or  IV,  as  required  for  individual  cases. 


Sometimes  there  is  obscure  pain  either  of  neural- 
Diagnosis    gic    character,    from    mild   pulpitis    or    impacted 

teeth.  In  the  latter  case  the  radiograph  can  be 
used  for  diagnosis,  but  in  the  former  it  is  of  little  use.  The 
pain  may  be  referred  to  another  part,  and  can  be  located  with 
local  anaesthesia.  Inject  for  the  suspected  tooth,  if  your  diag- 
nosis was  correct  the  pain  will  stop. 


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116 


ORAL   ANAESTHESIA 


Fig.  74.     Patient  between  70-80  suffered  for  years  with  severe  pains  of  neuralgic 
character.     The  Radiograph  shows  pulp  stones  in  the  first  and  second  mandib- 
ular molars.       I  used  the  pterygo-mandibular  injection    and   removed   the   pulps 
from  both  teeth.     The  pain  did  not  recur. 


2.     GROWN  AND   BRIDGE  WORK 

In  crown  and  bridge  work  we  perform  the  most  radical 
dental  operations.  Not  only  do  we  have  to  cut  off  more  tooth 
substance  than  when  excavating,  but  it  is  especially  the  grind- 
ing which  causes  a  great  deal  of  pain  and  discomfort.  Also  it 
is  frequently  necessary  to  devitalize  sound  teeth.  The  fitting 
of  bands  and  cementing  of  the  crown  or  bridge  is  also  a  painful 
process.  At  the  other  hand,  it  is  of  greatest  importance  that 
this  work  be  performed  exactly,  because  if  a  tooth  is  not  per- 
fectly prepared  it  is  impossible  to  fit  a  crown  which  does  not 
irritate  nor  invite  decay.  One  can  safely  say  that  failures  in 
bridge  work  result  more  from  not  being  radical  enough,  than 
from  any  other  cause,  and  this  again  in  most  cases  is  due  to 
pain. 

There  is  only  very  superficial  anaesthesia  re- 
Fitting  Bands  quired  for  fitting  bands  and  cementing 
and  Gement-  bridges.  Injections  into  the  gingival  margins 
ing  Bridges  are  sufficient,  but  are  usually  more  or  less  pain- 
ful. One  also  can  inject  between  the  gum  and 
tooth,  this  requires  great  pressure.  A  sufficient  way  is  to  apply 
a  twenty  per  cent  solution  of  Novocain  with  brush  or  cotton. 


Fig.   75.     Crown   and    ln'idge   case   1,   before   treatment. 


I*l0.  76.     (Jrown  and  InidKC  ca.sc   I,  after  ircalnunl. 


118  ORAL    ANAESTHESIA 

In  bridge  work  there  is  usually  more  than  one 
Grinding  and  tooth  to  be  operated  upon.  The  conductive 
Devitalizing  method  is  therefore  an  ideal  help.  Also  the  infil- 
tration method  is  sometimes  advisable.  Usually 
it  is  of  benefit  to  anaesthetize  both  the  teeth  and  soft  tissues. 
Injections  given  in  Tables  I,  II,  III  or  VI  can  be  used  as  re- 
quired. 

Case  I.  The  author  prepared  with  one  pterygo-mandibular 
injection,  all  the  left  mandibular  teeth  to  serve  as  abutments  in 
case  figure  75.  The  lower  second  molar  was  devitalized,  cuspid 
and  lateral  ground  for  open-faced  crowns,  and  one  bicuspid 
root  extracted,  all  in  one  sitting.  In  the  upper  jaw  I  injected 
for  the  two  bicuspids  on  the  buccal  side  by  the  infiltration 
method,  separate  for  each  tooth.  I  devitalized  and  cut  these 
off  for  banded  post  crowns  to  be  attached  together,  with  a 
dummy  on  either  side.  Figure  76  shows  case  finished;  in  the 
lower  jaw  a  sanitary  bridge,  with  j)orcelain  chewing  surface 
from  lower  left  lateral  to  second  molar. 

Case  II.  (Fig.  77.)  I  have  used  the  zygomatic  injection 
to  devitalize  the  first  maxillary  molar.  It  was  repaired  with  a 
large  hand-carved  porcelain  crown  to  fill  in  the  spaces  on  either 
side.  The  two  maxillary  bicuspids  I  devitalized  with  the  infil- 
tration method  horizontal  injection.  The  central  lateral  and 
cuspid  were  anaesthetized  by  the  horizontal  injection,  com- 
bined with  the  incisive  injection  to  extract  the  two  latter  on 
account  of  their  position.  The  central  incisor  I  devitalized  for 
a  banded  post  crown.  In  the  lower  jaw  I  used  the  pterygo- 
mandibular injection,  to  prepare  the  second  molar  for  an  all 
metal  crown,  to  devitalize  the  first  bicuspid  for  a  banded  post 
crown,  and  the  cuspid  for  a  half  crown  with  post.  All  the 
grinding  and  most  of  the  fitting  was  done  under  local  anaes- 
thesia.    Fig.  78  shows  the  case  completed. 


Fig.  n .     Crown  and  bridge  case  II,  before  treatment. 


"JG.   78.     Crown    and   Ijridge   case    II,   after  treatment. 


120  ORAL   ANAESTHESIA 

EXODONTIA 

Many  general  practitioners  gave  up  extracting  on  account 
of  the  disturbances  which  often  accompany  the  administration 
of  a  general  anaesthetic.  The  patients,  however,  have  great 
trust  in  the  family  dentist,  and  very  much  prefer  to  have  him 
do  the  extracting  instead  of  being  sent  to  a  specialist.  This 
has  as  a  consequence  that  frequently  roots  are  suffered  to  be 
left  in  the  mouth,  being  there  a  continuous  source  of  infection 
and  condemnation.  The  general  j)ractitioner  also  frequently 
fears  to  take  upon  himself  the  responsibility  of  administering 
a.  general  anaesthetic,  and  is  not  sure  to  be  able  to  accomplish 
under  the  unfavorable  circumstances  of  such  an  anaesthetic 
a  successful  operation.  Under  local  anaesthesia  the  most  dif- 
ficult extractions  are  easily  accomplished.  Everything  is  fav- 
orable, there  is  plenty  of  time  to  cut  the  gaim  to  get  access  to 
badly  decayed  roots,  and  if  a  root  is  broken  there  is  lots  of 
time  and  the  best  possibilities  to  get  it  out. 

Extractions  always  have  been  accomplished  more  or  less 
painlessly  with  injections  into  the  gmm  ]3roducing  a  gingival 
velum.  This  of  course  anaesthetized  as  a  rule  the  soft  tissues 
only,  and  was  painful  on  account  of  the  pressure  required  for 
the  injection.  The  extraction  itself  was  only  i^artly  painless 
because  the  dontal  ramus  supplying  the  tooth  and  alviolo-dontal 
membrane  was  not  reached,  and  the  anaesthesia  was  worthless 
if  a  broken-otf  root  had  to  be  taken  out,  especially  so  in  the 
lower  jaw. 

For  extraction  the  tooth  as  well  as  the  soft  tissue  has  to  be 
anaesthetized.  If  there  are  only  few  teeth  to  be  extracted,  and 
these  are  not  adjoining,  the  infiltration  method  can  be  used 
(Table  II)  if  it  is  not  contra-indicated  on  account  of  putrescent 
conditions  or  location.  For  the  lower  posterior  teeth,  infected 
areas  or  extensive  operations,  use  the  conductive  method  ( Table 
lY.)  The  anaesthesia  does  not  only  allow  the  extracting,  but 
also  curetting  of  the  sockets,  which  in  most  cases  is  of  greatest 


PILiCTICAL  APPLICA TION  OF  LOCAL  ANAESTHESL4    121 

importance.  The  tendency  of  late  lias  been  to  use  too  high  a 
percentage  of  suprarenal  substances  causing  too  great  anaemia. 
This  is  a  false  principle.  The  bleeding  should  be  normal  or 
almost  normal,  as  this  is  the  natural  cleaning  process  of  the 
wound,  toxins  and  other  products  of  inflammation  are  carried 
out  with  the  blood.  The  disadvantage  of  interfering  Avith  the 
normal  blood  circulation  is  also  obvious,  if  we  consider  that  a 
wound  in  the  mouth  is  continuously  exposed  to  infection,  anti- 
septic dressings  of  tooth  sockets  being  not  advisable,  as  the 
healing  process  should  l)e  tliat  of  organization  of  a  blood  clot. 

If  we  diminish  the  blood  circulation  of  the  wound  we  dim- 
inish also  the  natural  protection  against  infection;  we  give  the 
bacteria  one-half  or  one  hour's  time  to  multiply  and  take  pos- 
session. When  the  anaesthesia  and  anaemia  wears  finally  off, 
we  find  complications,  post-operative  pain  on  account  of  post- 
operative infection.  This  can  be  avoided  easily  if  we  use  the  T 
tablets,  which  contain  only  0.000,(12  gram  of  Suprarenin  to 
1  c.c. 

ORAL  SURGERY 

There  are  today  only  very  few  cases  of  dental  surgery  where 
local  anaesthesia  is  not  used  to  greater  advantage,  with  more 
safety,  promising  greater  success  of  the  operation,  and  less  dis- 
comfort to  the  patient  than  gen(n-al  anaesthesia.  The  only 
cases  where  it  cannot  be  used  are  cases  complicated  with  an- 
kylosis of  tlic  mandible. 

To  |»nt  paliciits  1(»  llic  sti-aiii  :iiid  danger  of  ctlici-,  chloro- 
foi-m,  oi-  siiuibir  general  anaesthelics,  witli  iheir  ])sychic,  and 
pliysic  pre-  and  after-effects,  for  oi-dinai-y  cases  of  exodontia  or 
oral  surgery  confining  a  ])alient  for  days  to  the  hospital  or  thc^ 
IkmI,  is  no  more  jnst  itnible.  If  we  conipare  I  wo  ojterat  ions,  side 
by  si(h',  one  niidei-  genei-;il  anaesi  liesJa,  with  month  ju-ops, 
g<Mieral  rehixation  (.('  the  patient,  I  lie  (idd  of  oiM'ralion  heing 
eontinnously  obscni-ed  l.y  increased  venons  bh'eding  and  saliva, 
not    to  spe;ik  of  bh)od  iind   |»ns,  wliieli   is  swaHowed  and  pene- 


122  ORAL   ANAESTHESIA 


trates  into  the  lungs,  the  operation  being  prolonged  by  endless 
sponging,  which  takes  up  more  than  half  of  the  time ;  and  com- 
pare the  other  under  local  anaesthesia  with  a  clear  view,  bleed- 
ing almost  obliterated,  and  cooperation  of  the  patient,  we  find 
it  easy  to  choose;  and  it  also  makes  it  clear  why  it  is  for  the 
operator  to  choose,  and  not  for  the  patient. 

Since  the  introduction  of  conductive  and  spinal  anaesthesia 
general  anaesthesia  has  become  less  popular.  The  progress 
which  local  anaesthesia  has  made  in  modern  surgery  is  shown 
in  the  report  of  the  university  clinics  of  Marburg  and  Heidel- 
berg, where  of  all  operations  fifty  respectively  fifty-four  per 
cent  have  been  performed  under  local  anaesthesia.  It  is  espe- 
cially used  on  the  head  (cranium  and  face)  neck,  ribs,  hemor- 
rhoids and  all  operations  on  the  extremities.*  Also  the  public 
has  quickly  become  accustomed  to  local  anaesthesia,  and  has 
great  faith  in  this  new  method,  which  is  less  disagreeable  and 
less  dangerous. 

For  large  surgical  operations  ganglion  anaesthesia  is  used; 
for  smaller  operations  the  conductive  method  is  recommend- 
able.  But  it  should  be  combined,  however,  with  the  infiltra- 
tion method,  to  anaesthetize  the  anastomosis  from  buccinator, 
facial  or  infra-orbital  nerves,  and  in  some  cases  to  get  anaemia 
of  the  field  of  operation.  Use  the  T  tablets  for  conductive  and 
ganglion  anaesthesia ;  the  T  or  E  tablets  for  infiltration  anaes- 
thesia; the  T  tablet  if  anaemia  is  not  required;  the  E  tablet  if 
the  bleeding  needs  to  be  decreased  so  as  to  give  a  better  view 
of  the  field  of  operation. 

Local  anaesthesia  gives  the  general  practi- 
Operation  for  tioner  the  possibility  of  using  his  skill  for 
Granulum,  delicate  surgical  operations,  which  in  some 

Root  and  Apex  cases  are  the  only  means  to  retain  a  tooth 
Amputations         without  endangering  the  general  health  of 

the  patient.  Since  the  physician  as  well  as 
the  dentists  have  become  familiar  with  the  grave  significance 

*    Haertel:    Fortschritte  auf  dem  Gebiete  der  Local  Anaesthesie.  Zeitschrift    fuer    aeztliche 

Fortbildung    1914.   1. 


PRACTICAL  APPLICA  TION  OF  LOCAL  ANAESTHESIA    123 

of  ail  infected  apical  graiiuluiu,  which  often  is  the  focns  of  gen- 
eral diseases  of  toxic  or  infectious  cause,  and  since  the  radio- 
graph has  become  such  a  simple  and  popular  means  of  diag- 
nosis preventing  the  unconscientious  dentist  to  ignore  such 
cases  with  placid  remarks,  we  come  to  realize  that  our  treat- 
ment of  these  conditions  with  medicines  placed  into  the  root 
canal  is  not  sufficient,  and  that  we  have  to  extract  the  tooth 
and  curette  the  socket,  or  perforin  on  it  a  delicate  operation, 
which  on  account  of  its  j)resent  importance  I  will  describe  in 
detail. 

Indication.  1.  Surgical  treatment  is  indicated  in  all  teeth 
worth  saving  where  treatment  through  the  root  canal  is  unsuc- 
cessful, as  in  all  cases  where  the  root  is  affected,  absorbed  or 
gangrenous.  No  tooth  should  remain  in  the  mouth  with  granu- 
lating peridontitis,  giving  symptoms  of  soreness,  lameness  or 
pain  continuously  or  at  intervals.  So-called  gum  boils,  which 
enlarge  from  time  to  time,  or  sinuses,  come  under  the  same 
head,  and  are  of  severer  nature  than  the  first  named. 

2.  Surgical  treatment  is  indicated  in  cases  of  well-fitting 
crowns  or  bridges,  where  we  find  the  root  canal  of  an  abutment 
only  partly  filled. 

3.  Surgical  treatment  is  indicated  in  roots  which  oi; 
account  of  their  curving,  or  on  account  of  obstructions,  cannot 
be  filled  to  the  apex. 

4.  Surgical  treatment  is  indicated  in  teeth  which  have  been 
perforated  at  the  apical  part  by  root  canal  instruments. 

5.  Surgical  treatment  is  indicated  if  root  instruments  have 
been  broken  off  in  the  root  canals,  and  cannot  be  removed  from 
the  pulp  chamber. 

Difficulties.  These  operations  can  be  performed  in  all,  but 
are  easier  in  single-rooted  teeth.  If  working  at  the  buccal 
roots  of  flu*  iif)per  teetli  one  should  be  careful  not  to  perforate 
the  floor  of  the  antrum.     In  the  lower  bicuspids  the  mental 


124 


ORAL   ANAESTHESIA 


nerve  must  be  considered.  The  lower  second  and  third  molars 
and  the  npper  third  molars  are  the  most  unfavorable  teeth  to 
operate  upon  on  account  of  their  position. 

Anaesthesia.  Use  the  conductive  combined  with  the  infil- 
tration method  wherever  practical,  but  either  can  be  used  alone. 
Inject  as  to  Tables  TI  and  lY,  and  in  difficult  cases  use  the  E 
tablet  for  the  infiltration  injection  to  get  anaemia. 


INJECTION   FOR    OPERATION   ON    THE   LEFT   MAXILLARY    LATERAL   INCISOR 


Fig.  79.     Labial  injection. 


Fig.  80.     Palatal  injection. 


Operation.  The  operation  varies  according  to  the  cause. 
If  we  operate  for  a  granulum  it  is  sometimes  sufficient  to  cur- 
ette the  apex  and  the  socket,  removing  all  granulated  tissue. 
If  the  root  is  affected,  partly  absorbed  or  gangrenous,  if  the  root 
filling  does  not  extend  through  the  apical  foramen,  or  if  the 
apex  is  perforated,  it  is  necessary  to  amputate  the  apical  part 
of  the  root.  If  a  foreign  body  is  to  be  removed,  it  is  often 
sufacient  to  cut  a  window  on  the  front  surface  of  the  root,  and 
remove  it  tlirough  the  pulp  chamber. 


PRACTICAL  A  FPU  C  A  TION  OF  LOCAL  ANAESTHESIA    125 

Technique  of  Granulum  Operation.  The  root  canal  should 
be  treated  before  the  operatiou  is  performed.  The  canal  can 
be  filled  either  before  or  during  the  operation.  Sterilize  \yith 
iodin,  and  be  sure  to  have  the  root  filling  germ  proof  and  sealed 
tight,  or  the  filling  will  be  pressed  out  if  a  crown  with  post  is 
cemented  on.     This  is  accomplished  by  i)umi>ing  thinly  mixed 


Fig.  81.     Serie   showing   am])utati<)n   of   tlie   apex   of   tlic   lower   incisor.     No.    1 

(top)    Diagnosis  of  the  granulated  condition.     Nos.  2  and  3,  Treatment  before 

the   operation.     No.  4,   Result   after  the   operation. 

phosj)hale  (ciiiciil  into  I  lie  canal,  and  by  moistening  the  gutta- 
perclia  ])oiiil  with  Ihe  same  mixture,  before  inserting  it.  The 
gutta-penha  |)oiiil  is  packed  (h)\vn  into  Ihe  V(h}\  canal  with  a 
snital)le  instrument  to  get  a  (lose  fit  on  the  walls.  If  there  is 
a  wide  a])ical  foramen,  or  an  artificial  ])erforalion  at  the  a])ex, 
the  cement  ami  also  the  point  will  e.xteml  beyond,  if  the  fora- 
men   ;inil    |»;ii-t    (tf   Ihe   ajiical    root    can;il    is   cah-ilied,    the    root 


126 


ORAL   ANAESTHESIA 


should  be  amputated  at  the  place  where  the  fillmg  euds.     Pre- 
vious to  and  after  the  root  canal  filling,  we  take  a  radiograph 
for  guide  and  control  of  the  work. 
Instruments  used : 

1.  Eetractor. 

2.  Knife. 

3.  Pliers. 

4.  Periostial  Raspatorium. 

5.  Sharp  retractor. 

6.  Chisel  and  mallet  or  fissure  and  round  burrs. 

7.  Small  curette. 

8.  Scissors. 

9.  Sewing  outfit. 

To  perform  the  surgical  part  of  the  operation,  paint  the  line 
of  incision  with  tincture  of  iodine,  and  make  a  half-round  in- 
cision to  cut  loose  a  flap  which  is  separated  from  the  bone  with 
the  sharp  raspatorium;  it  is  then  retracted  with  the  sharp 
retractor  upward  in  the  upper  jaw,  and  downward  in  the  Jower 
jaw.  If  a  sinus  is  present  it  is  well  to  let  the  incision  go 
through  it.  The  retractor  is  held  by  an  assistant.  Remove 
the  alviolar  plate  to  uncover  the  infected  area. 


Fig.  82.     Showing  incision  for  operation  on  the  left  maxillary  lateral  incisor. 


PRACTICAL  APPLICA  TION  OF  LOCAL  ANAESTHESLi    127 

This  is  easy  as  the  bone  is  usually  partly  destroyed.  It  is 
important  to  have  a  clear  view  of  the  whole  extent  of  the  apex 
of  the  root. 

1.  Curetting  only  necessary.  If  the  apex  is  not  affected 
curette  the  root  and  alviolar  socket  and  remove  all  pathological 
tissue,  with  suitable  curettes.  The  most  difficult  part  to  reach 
is  the  part  behind  the  root,  which  can  be  curetted  with  a  large 
spoon  excavator. 

2.  Amputation  is  not  necessary,  but  Apical  part  of  root 
canal  is  not  filled.  If  the  root  serves  as  abutment  of  a  bridge, 
the  removal  of  which  is  not  wished,  but  the  root  canal  is  only 
partly  filled,  amputation  is  sometimes  not  advisable  because  it 
would  weaken  the  abutment.  In  these  cases  we  can,  after  re- 
moving the  granulum,  slit  the  root  with  a  round  burr  from 
front,  starting  from  the  apex,  till  we  reach  the  root  filling. 
This  part  of  the  root  canal  is  then  thoroughly  sterilized,  best 
with  iodine,  dried  out  and  carefully  filled  with  amalgam. 
Cotton  is  placed  in  the  cavity  to  prevent  parts  of  the  amalgam 
to  remain  unseen  in  the  wound.  The  amalgam  is  thoroughly 
smoothed,  the  cotton  removed  and  the  wound  washed  out. 


WINDOW   OPERATION   TO    REMOVE   BROKEN    OFF   BROACH 
IN    ROOT   CANAL 


8.3.     After   the   window  is  cut  and 
the  broach  exposed. 


Fig.  84.     After  filling  of  the  window. 


128 


ORAL   ANAESTHESIA 


3.  Window  Operation.  If  there  is  a  perforation,  we  cut 
it  smooth  and  for  retention.  If  a  foreign  body  is  lodged  in  the 
root  canal,  we  locate  it  with  the  Kadiograph,  cut  a  window  over 
it  and  with  a  suitable  instrument  push  it  into  the  pulp  cham- 
ber. Place  a  i)iece  of  cotton  into  the  cavity  to  prevent  it  from 
falling  out  unseen.  A  smooth  broach  of  sufficient  size  is  now 
placed  into  the  canal,  and  the  window  is  filled  with  amalgam, 
which  is  smoothed  off  carefully.  Again  prevent  amalgam  from 
falling  into  the  wound,  wash  out  and  close  the  wound.  Eemove 
the  broach  carefully  after  the  amalgam  is  hard  and  fill  the  root 
canal  at  a  subsequent  sitting. 


Fig.  85.     Radiographic   serie   illustrating  the   window   operation.     No.   1,   shows 
broken  instruments.     No.  2,  instrument  removed.     No.  3,   root   canal  and 

window   filled. 

4.  Root  amputation  and  Apex  amputations.  In  molars,  es 
pecially  in  pyorrhoetic  conditions  or  cervical  caries,  it  becomes 
sometimes  necessary  to  amputate  an  entire  root,  as  the  palatal 
or  one  buccal  root  of  an  upper  molar,  or  the  mesial  root  of  a 
lower  molar.  This  is  an  easy  operation.  To  amputate  the  apex 
only  requires  more  skill.  When  we  have  the  apical  part  of 
the  root  in  plain  view,  we  diagnose  whether  it  is  pathological. 
With  a  fissure  burr  we  cut  it  off  crossways  at  a  point  where  it 
is  healthy,  and  to  which  the  root  filling  extends.  Now  comes 
the  most  important  act,  the  removal  of  the  granulation  tissue. 
This  is  removed  with  a  curette  till  healthy  bone  is  visible  on 


OPERATION    FOR   APEX   AMPUTATION 


Fig.  86.     Root  of  the  tooth  is  exposed. 


Fig.  87.     After  amputating  the  root  and 
curetting  of  tlic  cavity. 


Fig.  88.     Sewing  of  the  wound. 


130 


ORAL   ANAESTHESIA 


all  sides.  All  margins  and  sharp  points  are  then  smoothed 
with  a  round  burr,  and  the  cavity  is  thoroughly  washed  out 
with  a  mild  antiseptic  solution.  This  is  dried  up.  Before 
sewing,  stimulate  the  wound  with  a  small  instrument,  to  invite 
bleeding  for  the  formation  of  a  blood  clot.  DraM'  the  flap 
down  and  sew  it  back  carefully  with  horsehair  stitches.  If  a 
wound  heals  by  first  intention,  the  stitches  can  be  removed  in 
three  days.  For  swelling  of  the  soft  tissue,  which  frequently 
occurs  after  such  an  operation,  apply  dry  heat.  If  the  blood 
clot  should  become  septic,  the  stitches  have  to  be  removed  and 
the  cavity  is  packed  with  iodoform  gauze  to  let  the  wound  heal 
from  the  inside  out.  This  is  not  an  ideal  result,  but  sufficient 
for  the  preservation  of  the  tooth. 


Fig. 


Impacted    lower    third    molars.     Both    have    been    removed    with    the 
pterygo-mandibular   injection. 


Impacted    Difficult  extractions  and  especially  the  removal  of 
Teeth  impacted  teeth  are  operations  which  become  more 

and  more  frequent  as  civilization  progresses.  The 
conductive  methods  are  advisable  for  anaesthesia,  and  it  is 
usually  not  necessary  to  produce  special  anaemia.  (Tables 
II  and  IV.)  If  we  do,  we  should  be  careful,  however,  to  pre- 
vent post-operative  infections.  The  injuries  caused  by  these 
operations  are  usually  very  deep,  and  if  we  have  anaemia  of 
the  field  of  operation,  packing  of  the  wound  with  : 

Euroform  paste 

^     Orthoform 40 

Europhen 60 

Liquid  petroleum s.  q.  to  make  paste 


PILiCriCAL  A F PLICA  TION  OF  LOCAL  ANAESTHESIA    131 

is  reooiinneiided.  In  all  cases,  frequent  rinsing  of  the  wound 
by  the  patient  and  washing  out  daily  by  the  operator  is  advis- 
able. If  the  wound  has  been  packed  one  can  stimulate  it  at  a 
future  sitting  to  bleeding,  to  get  a  blood  clot  filling  the  cavity. 
Then  there  is  no  anaemia,  and  infection  will  be  taken  care  of  by 
natural  means. 


Fig.  90.     Impacted  cuspids  under  bridgework. 

To  set  fractures  of  the  upper  or  lower  jaw,  we 
Fractures  of  nse  local  anaesthesia  to  advantage.  Whenever 
the  Jaws  the  conductive  method  can  be  used  it  is  to  be 

pi'cferred.  The  pterygo-mandibular  space  can 
be  reached  from  the  outside,  starting  at  the  inner  surface  of  the 
lower  border  of  the  mandible,  directing  the  needle  straight  up- 
ward into  tbe  ])teryg()-nian(libular  space.  Also  the  infra-orbital 
nerve  can  be  readied  from  the  outside,  extending  tlie  needle 
directly  in  and  injecting  into  the  infra-orbital  canal.  Also  tlie 
iidilti-atioii   iiictliod  iiives  sometimes  good  results. 


Cysts,  Tumors,    'l'<>  rf'inovc  small  growths  ou  the  jaws,  ])alate, 
Necrosis,  checks,  or  lii»s,  mc  again  use  the  conductive 

Odontoma  method    combined    with    infiltration    around 

tJK'  tissue  to  be  i-emoved. 


Nl 


Fig.    91.     Large    mandibular  cyst  with    unerupted    third    molar.     One    root    of  the  third 
molar   extends  below  the  lower  margin  of  the  mandible. 


PRACTICAL  APPLICATION  OF  LOCAL  ANAESTHESLi    133 

For  more  extensive  operations  it 
Cleft  Palate,  Hare  Lip,  is  usually  necessary  to  anaesthet- 
Amputation  ot  the  ize  the  whole  division  of  the  fifth 

Alviolar  Process,  nerve,    supplying    the    region    in 

Resection  of  Jaws  question.     For  cleft  palate  we  an- 

aesthetize the  second  division  with 
the  spheno-maxillary  injection.  Injections  into  the  incisive, 
posterior  and  accessory  palatine  foramina  are  also  indicated. 
For  amputation  of  the  superior  alviolar  process,  the  zygomatic, 
infra-orbital,  incisor  and  post  palatine  injections  are  sufficient 
For  amputations  of  the  lower  alviolar  process,  use  the  pterygo- 
mandibular injection,  and  in  both  cases  condnne  the  conductive 
with  the  infiltration  method.  For  larger  operations,  as  ampu- 
tations of  the  upper  or  lower  jaw,  Haertel*  (clinic  of  the 
University  of  Berlin)  reconnnends  the  Ganglion  anaesthesia. 
He  describes  the  following  operations,  which  have  been  per- 
formed successfully  under  ganglion  anaesthesia :  Six  resections 
of  the  upper  jaw,  two  extirpations  of  the  tongue,  two  sarcoma 
of  the  nasopharynx,  on  orbital  tumor,  and  three  smaller  opera- 
tions about  the  jaws. 

*    Archiv   fuer   Klinische   Chirurgie,    Dezember,    1912. 


INDEX 


Abscess,  pericemental,  114 
Adjoining  teeth,  anaesthesia  of,  106 
After-effects,  96 
After-pain,  97 
Alcohol  jar,  54 
Alviolar  abscess,  acute,  112 
Alviolar  abscess,  chronic,  113 
Alviolar  process  of  the  mandible,   12 
Alviolar  process  of  the  maxilla,  11 
Ampules     with     Novocain     Suprarenin 

solution,  47 
Amputation  of  alviolar  process,  133 
Amputation  of   root,   128 
Amputation  of  root  apex,   128 
Anaesthesia,  conductive,  60,  71 

ganglion.  60,  91 

infiltration,  60,  63 

not   obtained,  93 

prolonged,  97 

spinal,  60 

surface,  60,  62 

undesirable  symptoms,  94 
Anaemia  in  extraction,  120 
Anatomy  of  the  oral  cavity,  9 
Apex  amputation,  128 
Antidotes   for  fainting,  96 
Antrum  of  Highmore,  14 
Arterio  sclerosis,  49 
Author's     method     of     preparing     the 
solution,  48 

B 

Bicuspids,  anaesthesia  of  mandibular, 

106 
Bier,   7 
Braun,  8,  60 


Braun's    requirements    of    a    substitute 

for  cocaine,  39 
Buccinator  injection,  84 
Buente,  8 


Calcified  pulps,  removal  of.  111 

Canine  fossa,  9 

Cardiac  disorders,  49 

Cavity  preparations,  106 

Cementing  bridges,  116 

Chronic  alviolar  abscess,   113 

Cleft  palate,  133 

Cocaine,  7,  39 

Conductive  anaesthesia,  71 
in  the  mandible,  li 
in  the  maxilla,  85 

Conductive  method,  60 

Crown  and  bridge  work,  116 

Cups  to  prepare  solution,  54 

Curetting  of  alviolar  sockets,  120 
technique,  127 

Cysts,  131 


Distilled  water,  50 

Femel  apparatus,  51 
Devitalization  of  normal  teeth,  107,  118 
Diagnosis  of  pain,  114 

E 

EiNHORX,  8,  39 
Euroform  paste,  100,  130 
Exodontia,  120 
External   oblique    line,  20 
Extraction  of  teeth,  120 


136 


INDEX 


Failures     and     ill-effects     in     "Local 

Anaesthesia,"   93 
Fainting,  96 
Fear,  98 

Femel  apparatus,  51 
Fischer,  8 
Fitting  bands,   116 
Foramen,  incisive,  14 

infra-orbital,    11 

mandibular,  21,  22 

mental,  19,  23 

palatine,  14 

posterior   superior  alviolar,   14 
Foreign  body  in  root  canal,  128 
Fractured  jaws,  131 

G 

Ganglion  anaesthesia,  60,  91 

"General    Anaesthesia"    versus    "Local 
Anaesthesia,"  7,  93,  121 

Granulum   of   the   alviolo-dontal  mem- 
brane,  113 

Granulum   operation,   122 
technique,  125 

H 

Haertel,  8,  133 

Halsted,  72, 

Hare-Hp,  133 

Hauptmeyer,  8 

Hypertrophied  pulps  removed,  111 

I 

Ill-Effects   in   Local  Anaesthesia,  93, 

99 
Impacted  teeth,   130 
Incisive  foramen,  14 

injection,  89 
Incisors,     anaesthesia     of    mandibular. 

106 
Infection  from  injection,  97 

post-operative,  99,  121 
Infiltration   anaesthesia,   history,  8 
method,  60,  63 

in  the  mandibula,  69 
in  the  maxilla,  63 


Inflamed  pulps,   removed,   112 
Infra-orbital  foramen,  11 

injection,  86 
Injection,  buccinator,  84 

Gasserian  ganglion,  91 

horizontal,  70 

incisive,  89 

infra-orbital,  86 

mental,  81 

on   labial    and  buccal   side   of  the 
maxillary  teeth,  66 

on   labial    side    of   mandibular   in- 
cisors, 70 

on  lingual  side  of  mandibular   in- 
cisors, 70 

on     palatine      side     of     maxillary 
teeth,  68 

posterior   palatine,   90 

pterygo-mandibular,  74 

rules,  101 

spheno-maxillary,    90 

tables,  102,   103,  104,  105 

zygomatic,  85 
Insertion    of    needle,    preparing    place 

for,  65 
Instrumentarium,  54 
Internal  oblique  line,  21 

pterygoid  muscle,  21 
Introduction,   7 


Jar  for  syringe,  54 
Jaws  fractured,  131 
Jaws,   resection  of,    133 

K 

Kalium  bromide — See  potassium  bro- 
mide 


Local  Anaesthesia,  60 

versus      general      anaesthesia, 
7,  93,  121 


M 


Mandibula,  14 
body,  19 
ramus,  20 


INDEX 


137 


Mandibular  nerve,  31 
Maxilla,   9 
Maxillary  nerve,  25 
Maxillary  sinus,  14 
Mental  fossa,  19 

injection,  81 
Molars,  anaesthesia  of  mandibular,  106 

anaesthesia  of  maxillary,  106 
Moral.  8 
Mucous  membrane  of  the  mouth,  35 

N 

Nasal  anaesthesia,  63 

Necrosis,   131 

Needle  for  injection,  54 

Nephritis,  49 

Nerves,  anterior  palatine,  30 

anterior    superior    alviolar    ramu;:, 

28 

buccinator,  31 

inferior  alviolar,  34 

inferior   dental  plexus,  34 

inferior  dental  rami,  34 

inferior  gingival  rami,  34 

infra-orbital,  27 

infra-orbital   rami,  28 

lingual,  34 

mandibular,  31 

maxillary,  25 

mental,  34 

middle  palatine,  31 

middle  superior  alviolar  ramus,  27 

naso  palatine,  31 

ophthalmic,  25 

posterior  palatine,   31 

posterior  superior  alviolar  rami,  25 

spheno-palatine,  25 

spheno-palatine  ganglion,  28 

superior  dental  plexus,  28 

superior  dental  ramus,  28 

superior  gingival    ramus,  28 

zygomatic,  25 
Neurology,  25 
Novocain,  39 

clinical  tests,  40 

discovered,  8 

dosage,  41 

physiological   properties,  40 

production,  40 

pugglets,  107 

reaction,  40 


Novocain-Suprarenin   combined,   44 
Suprarenin  in  ampules,  47 
Suprarenin  in  solution,  47 
Suprarenin  in  tablets,  48 

O 

Odontoma^  131 

Oedema,  96 

Operation   for  granulum.   122 

for  granulum,  technique,   125 
Operative  dentistry,  106 
Ophthalmic  nerve,  25 
Oral  surgery,  121 
Osteology,  9 


Pain  post-operative,  99,  121 

Pericemental    abscess,    114 

Peridontitis  removal  of  pulps,  90 

Posterior  palatine  inject  on,  90 

Potassium  bromide,  96 

Practical   application  of  Local   Anaes- 
thesia, 101 

Preparing    of    the    solution.    Author's 
method,  48 

Preparing     of     the     solution,     Seidel's 
method,  47 

Pulp  chamber  of  teeth  changes,  101 

Pulps,  calcified,  removal  of.  111 
hypertrophied,  removal  of.  111 
inflamed,  removal  of,  112 
normal,  removal  of,  107,  118 
with  pulp  stones,  removal  of,  111 

Q 

Quantity    of    solution   to  be   injected 
at  one  time,  41 

R 

Ramus  of  mandible,  20 
Removal  of  calcified  pulps,   111 
hypertrophied   pulps.    111 
inflamed   pulps,    112 
normal  pulps,  107 
pulps  with  pulp  stones,  111 
pulps  with  peridontitis,   112 
Requirements    of    a    solution    prepared 
frrim  tablets,  58 


138 


INDEX 


Resection  of  jaws,  133 

Ringer   solution,  50 

Ringer  tablets,  50,  57 

Root  amputations,  128 

Root  canal  with   foreign  body,   128 

Rules  for  injections,  101 


Seidel,  8 

Seidel's  Sixteen  Theses,  44 

method   to  prepare   Novocain   Su- 
prarenin  solution,  47 
Sharpening  of  the  needle,  54 
Solution,  preparing  of,  58 

requirements     if     prepared     from 

tablets,  58 
preparing.  Author's  method,  48 
Spheno-maxillary   ganglion,   28 

injection,  90 
Spinal  anaesthesia,  60 
Steinkamm,   8 

Submucosa  of  mucous  membrane,  35 
Substitute     for     cocaine,     Braun's     re- 
quirements, 60 
Sulcus  mandibularis,  21 
Suprarenin   syntheticum,  41 

chemical  properties,  42 
clinical  experiences,  42 
dosage,  42 

physiological  properties,  42 
production,  41 
reaction,  42 
Surface  anaesthesia,  60,  62 
Symptoms,    during    anaesthesia,    unde- 
sirable, 94 
Syringes,  54,  56 


Table  I.     Infiltration      anesthesia      of 

the  teeth  only,  102 
Table      II.        Infiltration     anaesthesia 

of  the  teeth  and  soft  tissue,  103 
Table     III.     Conductive  anaesthesia  of 

the  teeth  only,  104 
Table     IV.       Conductive     anaesthesia 

of  the  teeth  and  soft  tissue,  105 
Tablets  of  Novocain  Suprarenin,  48 
Tablets  E,  49,  54 
F,  49,  54 
F  +  E,  57 
Ringer,  50,  57 
T,  48,  54 
Teeth  impacted,  131 
Topography,  35 
Tuber  maxillare,  11 
Tumors,  131 

U 

Undesirable   symptoms  during  anaes- 
thesia, 94 


Valyl,  96 


W 


Waiting  time  of  anaesthesia,  106 
Window  operation,  128 
Wisdom  teeth  impacted,  130 


Zygomatic  fossa,  11 
injection,  85 
process,  11 


LIST  OF  ILLUSTRATIONS 


FxG.  Page 

1.  Outer  surface  of  maxilla  and  mandibula  showing  attachments  of  muscles  10 

2.  Skull  showing  small  foramina  in  the  incisor  region  of  the  maxilla  and 

mandibula        12 

3.  Skull   showing  foramina   in   the   cuspid,  bicuspid  and  molar  regions  of 

the  maxilla  and  absence  in  the  mandibula 13 

4.  Palate  of  a  child  6-7    years IS 

5.  Palate  of  a  child  11-12   years 15 

6.  Palate   of   an    adult 16 

7.  Palate  of  senile  skull 16 

8.  Skull   with   dissected  anterior  superior   alviolar   canal 17 

9.  Radiograph  showing  a  frontal  aspect  of  the  maxillary  sinus  ....  18 

10.  Cross    section   through    maxilla    and    mandibula    showing   difference    in 

make-up  of  the  bone 19 

11.  Three    mandibles    showing    different    construction    of    the    post    molar 

triangle        20 

12.  Sulcus  mandibularis  enclosed  by  the  dotted  line 2) 

13.  Specimen  showing  dissected  mandibular  canal 22 

14.  Variations  of  the  internal  surface  of  the  ramus  mandibularis       ...  23 

15.  Location  of  mental  foramen  in  a  child 24 

16.  Location  of  mental  foramen  in  adult 24 

17.  Location  of  mental    foramen   in   senile   skull 24 

18.  Nerves   trigeminus;    ( Vth   cranial   nerve) 26 

19.  Schematic  drawing  of  the   Nervus   maxillaris 27 

20.  Nervus  trigeminus    (Vth    cranial   nerve) 29 

21.  Schematic    drawing    of    ganglion    spheno-palatinum        50 

22.  Nervus  trigeminus:   (Vth  cranial  nerve).     In  the  maxilla  showing  the 

anterior  part  of  the  N.  maxillaris.     in  the  mandibula  showing  the 

N.    mandil)ularis 32 

23.  Schematic  drawing  of   nervus    mandibularis S3 


140  LIST  OF  ILLUSTRATIONS 

Fig.  Page 

24.  Section  through  the  upper  jaw  in  the  incisor  region 36 

25.  Horizontal   section   through   human   head  in  the   plane   in   which  man- 

dibular conductive   anaesthesia  is   best  accomplished 37 

26.  Femel  apparatus  to  produce  distilled  water 51 

27.  Schematic  drawing  of  distilled  water  apparatus 52 

28.  Bottle  for  Ringer  solution.     Jar  filled  with  absolute  alcohol.     Syringes 

and  dissolving  cups,  and  glass  tray 55 

29.  Syringes       .     '. 56 

30.  Large  and  small  dissolving  cups 56 

31.  Schematic    illustration    of    the    methods    of    local    anaesthesia    recom- 

mended  for   dental   surgery 61 

32.  Frontal  section  through  the  molar   region   showing  buccal  and  palatal 

injection  by   the   infiltration  method 64 

33.  Position  of   operator   when   injecting   for   an   upper   tooth  by  the   infil- 

tration   method 65 

34.  Radiograph  showing  the  infiltration  method   for  an  upper  incisor   .      .  66 

35.  Radiograph  showing  the  infiltration  method  for  an  upper  cuspid  ...  67 

36.  Radiograph  showing  the  infiltration  method  for  an  upper  bicuspid   .      .  67 

37.  Wrong  position  of  needle 68 

38.  Right  position  of  needle,  opening  pointing  towards  the  bone  ....  68 

39.  Radiograph  showing  the  infiltration  method  for  a  lower  incisor  ...  69 

40.  Radiograph   showing  the  horizontal  injection   for  bicuspid,  and  molar 

region         70 

41.  Radiograph  showing  the  horizontal  injection  in  a  coronal  section    .      .  71 

42.  Conductive    Anaesthesia:    1.  Zygomatic    injection.    2.  Infra-orbital    in- 

jection.    3.  Pterygo-mandibular  injection.     4.  Mental  injection   .      .  72 

43.  Diagram   showing  injection  into  the  pterygo-mandibular  space    ...  74 

44.  Technique  of  inserting  the  needle  for  the  pterygo-manidbular  injection  75 

45.  Pterygo-mandibular  injection  on  the  right  side;  position  on  patient     .  76 

46.  Pterygo-mandibular  injection  on  the  right  side;  position  on  patient     .  77 

47.  Pterygo-mandibular  injection   on  the   left   side;    position   on  patient     .  78 

48.  Pterygo-mandibular  injection   on  the  left   side;   position   on   patient     .  79 

49.  Sulcus    mandibularis    with   needle 80 

50.  Radiograph  showing  needle  inserted"  in  right  position  above  the  lingula  82 

51.  Radiograph  showing  needle  inserted  too  low,  sliding  along  the  lingula 

into  the  muscle 82 


LIST  OF  ILLUSTRATIONS  141 


T^  Page 

Fig. 

52.  Radiograph  showing  the  pterygo-mandibular  injection 83 

53.  Radiograph   showing  injection  into  the  mental  foramen 84 

54.  Infra-temporal   surface  of  the  maxilla 85 

...  07 

55.  Radiograph   showmg  zygomatic   mjection °' 

56.  Infra-orbital  injection  on  the  right  side 88 

57.  Radiograph   showing  infra-orbital   injection 

58.  Schematic  drawing   showing  the   injection   into  the  Gasscrian  ganglion       91 

59.  Foramen  ovale  in  the  skull   seen  from  the  position  of  the  operator     .       92 

lAQ 

60.  Radiograph  of  maxillary    incisors 

108 

61.  Radiograph  of  cuspids 

62.  Radiograph  of  maxillary  first  bicuspids 108 

63.  Radiograph  of  maxillary    second    bicuspids 108 

1 0Q 

64.  Radiograph  of  maxillary    molars        

65.  Radiograph  of  mandibular   incisors 

66.  Radiograph  of  mandibular    bicuspids 109 

67.  Radiograph  of  mandilmlar  molars 

68.  Central  incisor  with  chronic  abscess    (lead  filling),  lateral  incisor  with     ^^^ 

pulpitis 

69.  Root   of   lower    second   bicuspid 

70    Acute   alviolar   abscess  of  a  central  incisor H^ 

,   .   ,         ,  ...     114 

71.  Chronic    alviolar   abscesses 

72.  Pericemental  abscess  caused  by  perforation  of  the  tooth  by  a  post     .      115 

73.  Pericemental  and  alviolar  abscess  on  a  maxillary  cuspid 115 

74.  Patient  suffered  with  severe  pains  of  neuralgic  character.     The  Radio- 

graph shows  pulp   stones 

117 

76.  Crown  and  bridge,  case   1,    after    treatment 


graph  shows  pulp   stones 

75.  Crown  and  bridge,  case   I,   before  treatment 

117 


119 

77.  Crown  and  bridge,  case  II.  before  treatment 

119 

78.  Crown  and  bridge,  case   11.  after  treatment 

.       .  124 

79.  Labial    injectK)n     

...  124 

80.  Palatal    injection         

81.  Serie  showing  amputation  of  the  apex  of  the  lower  incisor     .      .      .      .      12o 

82.  Shr.wing  incision  for  oi)eration  on  the  left  maxillary  lateral  incisor       .      126 

83.  .'\ftcr  the  window  is  cut  and  the  broach  exposed 


1 42  LIST  OF  ILL  US TRA  TIONS 

Fig.  Page 

84.  After  filling  of  the  window 127 

85.  Radiographic  serie  illustrating  the  window   operation 128 

86.  Root  of  the  tooth  is  exposed 129 

87.  After  amputating  the  root  and  curetting  of  the  cavity 129 

88.  Sewing  of   the  wound 129 

89.  Impacted  lower  third  molars   . 130 

90.  Impacted    cuspids    under   bridge-work 131 

91.  Large  mandibular  cyst  with  unerupted  third  molar 132 


/I 


R^:.510 


T36 
Copy  1 


Thoma 

Oral  anaesthesia. 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsi.stx) 

RK510T36C.1 

Oral  anaesthesia;  local  anaesthesia  in  t 


2002369680 


